EI Colorado Autism Guidelines

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  • 1. Early Intervention Colorado Autism Guidelines for Infants and Toddlers These guidelines and other materials are available at www.eicolorado.org
  • 2. Colorado Department of Human Services Division for Developmental Disabilities In Collaboration with The University of Colorado Denver School of Education and Human Development Phillip Strain, Ph.D., Principal Investigator Acknowledgements The Colorado Department of Human Services, Division for Developmental Disabilities would like to thank the families, early intervention staff and advocates who provided input on the Early Intervention Colorado Autism Guidelines for Infants and Toddlers. Suggested citation:Early Intervention Colorado Autism Guidelines for Infants and Toddlers (2010). Developed by the University of Colorado Denver, PELE Center, under contract with the Colorado Department of Human Services, Division for Developmental Disabilities (H393A090097). Permission to copy not required—distribution encouraged. Electronic version posted at www.eicolorado.org. Funded by the American Recovery and Reinvestment Act of 2009.
  • 3. Table of ContentsPreface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iiIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Guiding Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Detailed Guidance for Key Practice Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Strategies for Designing Individualized Family Service Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 A Tiered Model for Thinking About Specific Needed Early Intervention Services . . . . . . . . . . . . . . . . . . 11 Implications for Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Evidence-Based Interventions and Measuring Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Established Interventions in the National Standards Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Monitoring Progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Making Smart Decisions about Data Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Appendix A—Questions to Guide the Individualized Family Service Plan Planning Process for Children with Autism Spectrum Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Appendix B—About Our Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Early Intervention Colorado Autism Guidelines for Infants and Toddlers i
  • 4. PrefaceIn July 2009, the Colorado Department of Human mandates that appropriate services be based onServices, Division for Developmental Disabilities, scientifically based research, are available statewidewith funding from the American Recovery and to all infants and toddlers, and meet theReinvestment Act of 2009, began collaborating with individualized needs of the eligible child and family.the University of Colorado, School of Education and The Guidelines are organized in different sections toHuman Development to develop the Early address the various target audiences of thisIntervention Colorado Autism Guidelines for Infants document. While anyone who has an interest in theand Toddlers. The purpose of these Guidelines is to provision of or receipt of early intervention servicesensure that infants and toddlers, birth through two for infants and toddlers with ASD will benefit fromyears of age,who have a diagnosis of, or reading the entire document, the “Guiding Principles”characteristics of Autism Spectrum Disorders (ASD) section is essential reading for all—administrators,receive early intervention services based on their policy makers, providers, families, and advocates.individualized identified need, and not on a Other sections of the Guidelines may be of more orprescriptive curriculum or treatment model. less utility to various readers. For example, all earlyThe Guidelines document is also intended to assist intervention providers working with infants andlocal early intervention programs to provide early toddlers with ASD and their families should beintervention services that are derived from evidence- familiar with and directly incorporate into theirbased practices, published research and early practice the strategies suggested in the “Designingchildhood clinical judgment that will increase the Individualized Family Service Plans (IFSP)” section.awareness and knowledge of families, providers, and Similarly, teams of providers and programearly intervention administrators. administrators may find the “Tiered Model for Thinking About Specific Needed Services” section toThe content of the Guidelines is compiled from a be useful in the overall design of systems and thereview of research-based programs and models, as allocation of resources. Families and providers arewell as state-of-the-art information from experts in always keenly concerned about the use of specificthe field of Autism Spectrum Disorders, and work practices with the best chance of producing desiredwith family members who have infants and toddlers outcomes. These readers may well find particularlywith ASD. The Guidelines approach early intervention valuable information in the “Evidence-Basedservice decisions consistent with the Individuals with Practices and Measuring Outcomes” section.Disabilities Education Act of 2004 (IDEA) thatii Early Intervention Colorado
  • 5. IntroductionThe arrival of a new baby brings joy and happiness to A diverse collection of behavioral patterns arefamilies. This new beginning is met with anticipation exhibited by children with ASD. These behavioraland the desire to love and nurture the new family patterns are observed across multiple developmentalmember. Most parents follow their child’s areas and are highly distinctive (Volkmar, 1999). Thisdevelopmental milestones very closely. They watch diversity in the expression of ASD is what presentsand observe, compare achievements to that of others the greatest challenge for professionals and parentsthe same age, read informational books, search the looking for the most appropriate early interventioninternet, and ask questions of their primary care approaches. Each child requires an individuallyphysician, friends, childcare providers, or anyone tailored program of services in which the mostwho may offer some reassurance and insight on their appropriate collection of services is not always clear.child’s development. The child’s lack of specific social communication skills often hinders the child in expressing wants andDespite extensive information available to parents needs, regulating the actions of others, and engagingabout early childhood development, there are times in reciprocal social interactions. These deficits ina family is faced with puzzling questions about their particular result in the need for careful teachingchild’s development. They may wonder why their strategies to facilitate learning in young children withchild is not babbling by 12 months of age, or why he ASD. Early intervention services are very importantor she does not seem to relate to other children for enhancing the development of infants andduring story time at the library. What about those toddlers with disabilities, and they are especiallyscreaming episodes every time mom tries to crucial in determining the future language, social andcomfort? When a parent or referral source expresses behavioral outcomes of very young children withconcerns about a child’s language and ASD (National Research Council, 2001).communication, social, and behavioral development,it merits deeper questioning to analyze the root of The Early Intervention Colorado Autism Guidelinesthese issues and explore supports and services that for Infants and Toddlers offer a general orientationcan address these concerns. to the design and delivery of high quality services to infants and toddlers with ASD who are receivingAutism Spectrum Disorders (ASD) are neurological, early intervention services in Colorado. Thepervasive developmental disorders characterized by document is divided into three major sections. First,patterns of delay and difference in the development the reader will find a set of twelve Guidingof communication, social, and behavioral skills Principles that outline Colorado’s general guidance(Volkmar, 1999). The onset of these conditions around the development, implementation andgenerally takes place in the first years of life, and monitoring of early intervention services for infantsthese conditions may manifest in varying degrees and toddlers with ASD. The next major sectionboth across and within individuals. ASD affects provides more detailed information and guidanceindividuals of all socioeconomic levels and different around key practice issues for all providers andcultures (Autism Society of America, 1990; Scott, recipients of early intervention services including:Clark, & Brady, 2000). In the 1990s, it was believedthat ASD affected one out of every 250 individuals • Strategies For Designing Individualized Family(Brison, Clark, & Smith, 1988; Ehlers & Gillberg, Service Plans (IFSPs)1993; Sugiyama & Partington, 1998). More recent • A Tiered Model For Thinking About Specificfindings reflect an increase in prevalence and it is Needed Early Intervention Servicesnow believed that one out of every 150 individuals • Implications for Implementationcould be diagnosed within the autism spectrum(National Autism Center’s National Standards Project The final section provides detailed information on theReport, 2009). Established Interventions for individuals with ASD, case studies, strategies for monitoring progress and information about using data. Early Intervention Colorado Autism Guidelines for Infants and Toddlers 1
  • 6. Guiding PrinciplesThe crafting of this set of guidelines has been are done with the family. Families have a decision-influenced deeply by a set of principles that reflect making role as members of the IFSP team. The teamboth the science of early intervention as well as a determines who will be involved in the program, whencore group of values. These principles are: services will take place and what will be the focus of the services. Families determine how they will be1. Services must be individualized for each child involved in implementing their child’s IFSP. Even and family. though the intervention may follow a specific2. Family involvement and participation is critical. curriculum, the infusion of intervention into daily3. Early delivery of intervention must be encouraged. activities and routines must be customized for each family. Therefore, it is essential that the IFSP be4. Families have a right to evidence-based practices. sensitive to and respectful of the enormous diversity in5. Intervention is based on an individualized family life circumstances that impact family member’s developmental curriculum designed to address participation in intervention. The life circumstances the specialized needs of the infant or toddler with include, but are not limited to: family structure, income Autism Spectrum Disorders. stability, informal supports, coordination with other6. Intervention is planned and systematic. relevant services, etc.7. Infants and toddlers with Autism Spectrum Disorders should have regular and deliberate ■ Principle 2: exposure to typically developing peers. Family involvement and participation8. Challenging behaviors are addressed using is critical. positive behavioral interventions and supports. A goal of early intervention services is to help families9. Intervention should focus on developing meet the developmental needs of their infants and communication skills. toddlers. Families are the first and most important10.The development of social relationships is integral teachers for their children. They are the constant in to successful outcomes. their children’s lives. Infants and toddlers learn as they11.Getting to quality outcomes is not just about experience life with their families. Service systems and hours of direct services. personnel change over time, but families maintain the continuity from day-to-day and year-to-year. Families12.The transition from the early intervention program become lifelong advocates for their children. to preschool special education and related services should be well planned. Families need to be actively involved in their children’s program, at a minimum, in the following ways:Each principle is described in detail below. 1. Planning and helping to decide what services their children will receive;■ Principle 1:Services must be individualized for 2. Instructing and assisting with activities of daily living and developing strategies for addressingeach child and family. the needs of their children, and“Individualization” means that each child’s and family’s 3. Evaluating the progress of their children.services are based on that child’s needs, strengths and Relationships between families and professionalsinterests and the family’s concerns, priorities and should reflect a respectful reciprocity where bothresources. This is different for each child and family parties learn from each other. Family members arebecause each child and family is unique and has not expected to be primarily responsible fordifferent needs and values. The development of the delivering the specialized services on the IFSP,intervention plan, known as the Individualized Family however, they are absolutely necessary partners inService Plan (IFSP), and ongoing changes in the plan intervention.2 Early Intervention Colorado
  • 7. Autism Center’s National Standards Project report■ Principle 3: (2009) and the National Professional DevelopmentEarly delivery of intervention must Center on Autism Spectrum Disorders definition ofbe encouraged. evidence-based practices for children with ASD (2009). Moreover, families should have a right toEmpirical data support the value of early intervention services that address all the core deficits of ASD.(Fenske, Zalenski, Krantz & McClannahan, 1985;Harris & Handleman, 2000; Lovaas, 1987; Strain & Intervention selection is complicated and should beBovey, 2008). This makes a compelling case for made by a team of individuals who consider thepractices to expedite the delivery of services under unique needs and history of the infant or toddler withPart C of the federal Individuals with Disabilities ASD along with the environments in which he or sheEducation Act (IDEA). Therefore, parents and lives. However, in all cases, IFSP teams must selectproviders who suspect an infant or toddler of having established evidence-based practice (see “Evidence-ASD should insist on early screening. Based Interventions” section, pp. 17–27) for service delivery to any infant or toddler with ASD.To address this need for early screening, the M- Established Interventions have sufficient evidence ofCHAT™ (Modified Checklist for Autism in Toddlers) effectiveness. The IFSP team must give seriouswas developed for very young children older than 12 consideration to these interventions because a) thesemonths who show signs of ASD. It is designed to methods have produced beneficial effects for childrenscreen for social development, such as joint attention involved in the research studies published in theand pretend play, in comparison to typical infant and scientific literature and, b) access to methods thattoddler milestones. The M-CHAT™ can be useful in work can be expected to produce more positive long-narrowing down behaviors that may lead ultimately term outcomes. However, it should not be assumedto an ASD diagnosis for infants and toddlers and can that these methods will universally produce favorablehelp highlight the red flags associated with ASD so outcomes for all children with ASD.that early intervention can begin as soon as the childis found eligible for services. In addition to relying on Established Interventions first, the judgment of professionals with expertise inFamilies and children should not have to wait for working with the individual child with ASD must beearly intervention services while waiting for a medical taken into consideration (see “Strategies for Designingdiagnostic evaluation. The American Academy of IFSPs” section, pp. 9–11). Once methods are selected,Pediatrics recommends referring simultaneously for these professionals should collect data to determine ifa diagnostic medical evaluation and also to an early a method is effective. Professional judgment plays aintervention program as soon as an ASD diagnosis is particularly important role in decision-making when:suspected. Even without a formal diagnosis of ASD,children may qualify for and benefit from early 1. A method has been correctly implemented in the pastintervention services. and was not effective or had harmful side effects. 2. The method is contraindicated based on other■ Principle 4: information (e.g., the use of prompts for a childFamilies have a right to evidence- with a prompt dependency history).based practices. Moreover, the values and preference of the parents or other primary caregivers play an important role inPart C of the IDEA mandates that states have in effect a decision-making.policy that “ensures that appropriate early interventionservices based on scientifically based research, to the Finally, early intervention providers should be wellextent practicable, are available to all infants and positioned to correctly implement the selectedtoddlers with disabilities and their families…” (20 intervention. Developing capacity and sustainabilityU.S.C.1435(a)(2)). Families should expect that all of an established method may take a great deal ofservices delivered as part of the IFSP are based upon a time and effort, but all people involved in interventioncontemporary understanding of efficacious to infants and toddlers with ASD should have properintervention practices as articulated by the National training, adequate resources, and ongoing feedback Early Intervention Colorado Autism Guidelines for Infants and Toddlers 3
  • 8. about fidelity. Capacity plays a particularly importantrole in decision-making when: ■ Principle 6: Intervention is Planned and Systematic1. A service system has never implemented the intervention. Many evidence-based methods are Intervention is carefully planned, concentrated, and very complex and require precise use of systematic. It involves assessing, planning, teaching techniques that can only be developed over time. and consistent measuring of progress with each2. A professional is considered the “local expert” for intervention step. Each step is coordinated toward a a given method but he or she actually has limited meaningful set of outcomes or goals. The only formal training in the technique. reliable way to determine if the intervention is effective is to be systematic and to measure progress3. A service delivery system has implemented a on a regular basis. It is important to note that many system for years without a process in place to indicators that are easiest to measure, such as ensure the intervention is being implemented vocabulary, intelligibility of words, or duration of correctly (with fidelity). engagement may not be as meaningful or important to the family as the sense of the child and family’s■ Principle 5: quality of life, such as reduced frequency ofIntervention is based on a developmental tantrums, ease of transition between home and othercurriculum designed to address settings, or the ability of family members to spendthe specialized needs of the infant or quality time together.toddler with Autism Spectrum Disorders. Systematic instruction relies on interventionIFSPs for infants and toddlers with ASD should be decisions that are driven by the results of databased on widely accepted principles of child collection. Data is used to measure the change in adevelopment. The instructional program builds on behavior or skill over time. For example, data may bethese principles and the child’s individual strengths taken on the frequency (how often) a behavior doeswhile also addressing his or her unique needs. The or does not occur, the duration (how long) a behaviorcurriculum for a young child with ASD needs does or does not occur, and the independent natureconcentrated or specialized instruction to address the of a behavior (how much support or prompting aareas of language, social interaction, play skills and child needs). In order to use data in reviewing theinterests. The essential areas for a specialized effectiveness of intervention, the following mustcurriculum for an infant or toddler with ASD include: happen:1. Attending to and staying engaged in the 1. An assessment is completed prior to intervention; environment, including people and 2. Outcomes and objectives are written in developmentally appropriate play materials; measurable and functional terms. There must be a2. Using verbal and non-verbal communication, specific description of the desired behavior; such as gestures, vocalizations and words; 3. Data on outcomes and objectives are taken prior3. Understanding and using language to communicate; to intervention and used as a baseline for intervention;4. Playing appropriately with toys; 4. Steps or tasks towards outcomes are analyzed5. Playful interactions with others; and defined;6. Reciprocal interactions; 5. Instructional strategies and supports are identified7. Spontaneous interactions; (e.g., where, when, with whom, level of support);8. Making choices; 6. Methods for motivating or reinforcing the desired9. Following daily routines and variations in routines; behaviors are identified; and 7. Methods and timelines for measuring progress10.Addressing atypical sensory preferences and are determined; aversions.4 Early Intervention Colorado
  • 9. 8. Data is taken and analyzed on a routine basis; and and their behavior. The principles are grounded in the9. Adjustments in intervention plans are made based appreciation of each child’s strengths and needs. To on analyzing progress on the IFSP outcomes. practice PBIS means getting to know the whole child and assuming his or her behavior has meaning andOngoing collaboration between the family and service that the behavior is a form of communication. Itproviders in the analysis of data and adjustment of requires recognizing that a child develops andstrategies is a key to successful teaching and responds best when he or she is respected andlearning. Continuation of ineffective strategies or supported to enjoy relationships and make choices.relying on techniques merely because they have been Challenging behaviors displayed by a young childshown to be effective with other children may be with ASD are complex and may create frustration andharmful. Many early intervention providers find that a confusion for those who interact with the child.regularly scheduled meeting of all team members Behavior may range from aggression, tantrums, or(including the family) is important to review data, self-injury to withdrawal or repetitive, stereotypicalmaintain consistency in intervention, and make actions. Some of these behaviors also occur in atimely changes in the intervention. It is also essential child who is typically developing. For an infant andthat services are carefully coordinated and involve toddler with ASD, behaviors can be extreme, occurthe disciplines needed to address the unique needs of more frequently, disrupt development, or contributethe child and family. to high levels of stress among family members. Before developing IFSP outcomes and strategies to■ Principle 7: address problem behavior, a thorough assessment ofInfants and toddlers with Autism the behavior must take place. This assessment,Spectrum Disorders should have regular which may be referred to as a “functional behavioraland deliberate exposure to typically analysis,” is completed by the appropriate membersdeveloping peers. of the IFSP team and is designed to answer questions, such as “Why is the behaviorThis empirical and values based principle has, at its happening?,” “When does the behavior occur?,”core, two irrefutable facts. First, children with ASD “What function does the behavior serve?,” “Is theexperience significant social relationship delays that behavior preceded by any biological, environmental,represent primary diagnostic criteria (Luisell, Russo, sensory, and/or emotional conditions?” TheChristian, Wilczynski, 2008; Mahoney & Perales, 2003; assessment also looks at what happens after theStrain & Schwartz, 2009). Second, by a wide margin, behavior occurs, “How do people respond to thethe most effective intervention in this domain involves behavior?” The assessment helps the teamteaching typically developing children to be therapeutic understand how their response to the child’sresources (National Autism Center, 2009; Strain & behavior may increase or decrease the behavior.Bovey, 2008). For children ages birth through twoyears of age, this means involvement in Once the assessment is completed, a PBIS plan ispreschool/childcare settings, “play dates,” or planned developed as part of the IFSP. The plan includesinteractions between siblings, where the early developing strategies to keep the behavior fromintervention provider could facilitate peer training occurring, providing the child with new skills toscenarios. replace the undesirable behavior, and assisting family members or other caregivers to respond to the behavior in new ways. The ultimate goal of the■ Principle 8: plan is to help the child and family gain access toChallenging behaviors are addressed new activities and settings, have positive socialusing positive behavioral interventions interactions, develop friendships, and learn newand supports (PBIS). communication skills. The result of the support should be that the child has fewer problemPBIS (Carr et al, 2002) is a set of principles that behaviors and more typical ways of interactingframe how to think about and respond to children with others. Early Intervention Colorado Autism Guidelines for Infants and Toddlers 5
  • 10. Whether a child is using an alternative■ Principle 9: communication system or not, communicationIntervention should focus on developing interventions noted in the IFSP should focus on thecommunication skills. development of functional communication, including receptive and expressive language skills such asThe importance of having an effective communication getting someone’s attention, requesting,system cannot be underestimated. Communication is commenting, pointing to objects, asking for help andmuch broader than simply talking to others. A good greeting others appropriately.communicator uses verbal, as well as non-verbalbehavior to engage a listener. Infants and toddlerscommunicate to make their needs known long before ■ Principle 10:they can talk. As young children develop, their non- The development of social relationshipsverbal communication (i.e., pointing to desired object, is integral to successful outcomes.lifting their hands to be picked up) becomes naturaland is understood by others. Young children with In addition to difficulties with communication, infantsASD, whether verbal or non-verbal, must develop and toddlers with ASD typically lack appropriatesome type of communication system in order to be interaction and social skills. Intervention for a childsocially successful. They must be able to with ASD needs to specifically address this core,communicate in a manner that others will understand. defining characteristic as early as possible.Some toddlers with ASD lack verbal communication Promoting the social development of infants andwhile others with ASD may often have large toddlers with ASD must be one of the primary goalsvocabularies or imitate spoken language well, but lack of early intervention services, as is facilitating thejoint attention skills or functional use of language to ability of young children with social delays to developcommunicate. Alternative or augmentative appropriate friendships. With early and intensivecommunication systems are one way to assist a intervention, the seemingly pervasive social skilltoddler who has limited verbal language. The type of deficits of many children with ASD can be remediatedcommunication system used varies depending on the (Lovaas, 1987; McGee, Daly & Jacobs, 1993; Strain,child and the activities and environments in which he 1987). To successfully target these important skills,or she spends time. The system may include simple intervention efforts, even within early intervention,gestures, sign language, objects, pictures, or an must include: a) regular access to typical peers, b)electronic communication device. The use of an thoughtful planning of meaningful social situationsalternative system does not mean that the child does embedded throughout the day, c) the use of “social”not develop verbal language skills or speech. The toys, d) multiple-setting opportunities (home-communication system is used as an aid to improve inclusive, community-based) to practice emergingcommunication and speech, increase social social skills, and e) intensive data collection in orderinteractions, and provide structure to daily activities to make midcourse corrections to existingor routines. Because a child with ASD tends to have intervention plans (Strain & Danko, 1995).strong visual skills, he or she is often successful withpicture communication systems such as the PictureExchange Communication System (PECS) (Bondy & ■ Principle 11:Frost, 1994). If a child has difficulty understanding Getting to quality outcomes is not justspoken communication, pictures are often used to about hours of direct services.give more information. For example, a child may be There can be no doubt that achieving qualityoffered a choice of what he wants to play with by outcomes is first and foremost on the minds ofshowing him two pictures. The child chooses what he families affected by ASD. In many situations, and foror she wants by pointing to the picture or handing it many years, families and providers have assumedto the adult. The purpose of an alternative system is that getting a certain amount of hours of directto expand the ways in which the child can interact service or a certain intervention practice is thewith and be understood by a variety of people. essential ingredient to achieving quality outcomes.6 Early Intervention Colorado
  • 11. Regretfully, this simple and seductive formula is can assume that skill acquisition is occurring. Insteadhighly questionable and misleading. of asking, “How many hours of service are on the IFSP,” the alternative question could be, “Are theRelated to the amount of service hours, much of the IFSP outcomes, strategies and corresponding earlyfocus has been on an “estimated” 25 hours per week intervention services sufficient to influence the child’sthat was part of the National Research Council’s engagement across all daily routines (dressing,(2001) report on early treatment for ASD. Essentially eating, play, bedtime, etc.)?” Intensity with infantswhat the report authors did was add up the hours and toddlers must also be sensitive to the fact thatdelivered in eight preschool (not infant–toddler) essential interventions can be delivered across manymodels with varying efficacy data and then divided by routines by adult family members who have beenthe number of models to yield an average of 25 coached by providers in specific teaching strategies.hours. The models in fact ranged in hours from 15– Moreover, it should also be kept in mind that infants40 and the report clearly states that no clear outcome and toddlers with ASD (and any similar age children)differences were evident across hours. As was true require adequate time during the day for rest andthen, it is still the case that there are no credible sleep. Very young children are simply notstudies in which the same intervention has been “developmentally available” for the same level ofdelivered at different levels of hours. For a variety of intensive intervention as are older children.ethical and practical reasons, it is doubtful that suchresearch will ever be available. Factor 2. Fidelity of intervention delivery. Selecting anSimilarly, there has been a narrow focus on delivering “Established Intervention” does not guarantee thata singular intervention approach. Some individuals the infant or toddler will receive the intendedadvocate for only Pivotal Response Training, or approach. It is essential to ask what experienceDiscrete Trial Instruction, or Incidental Teaching, and providers have with the intervention approach, doso on. The problem is that these Established they have a protocol for judging that the interventionInterventions vary greatly in their relative efficacy for is correctly implemented and what are the plans ifcertain target behaviors. For example, Peer-Mediated intended outcomes are not forthcoming.Intervention has been shown to be the strongestevidence approach for target behaviors in the social Factor 3.domain. Incidental Teaching has been used almost Social validity of goals. Social validity refers to theexclusively with verbal language behaviors. degree to which there is an immediate impact on theSchedules are particularly helpful during transition child’s quality of life when a particular goal or objectivetimes, and so on. The point is that no one approach has been met. For example, teaching a toddler to labelcan hope to yield the best outcomes across all the colors when presented with 3x5 cards of differentlikely goals of any child or family. colors would have low social validity compared to teaching the same toddler color recognition when aIf a narrow focus on hours or a narrow focus on getting peer at an art table says, “Do you want some red?” ora certain intervention model is not recommended, then when his or her mom says, “Want your red or bluewhat are the relevant factors? There are five evidence- pajamas?” In the later cases, the child’s new colorbased factors that are suggested. knowledge can directly control his or her environmentFactor 1. and meet immediate needs. Therefore, this teachingIntensity. While hours of service may not be a goal would have high social validity.particularly valid measure of intensity, intensity is a Factor 4.highly relevant factor. The alternative view of intensity Comprehensiveness of intervention. One of theis based on several decades of research showing that more clear findings from the last several decades ofthe level of children’s active and appropriate intervention research on children with ASD is thatengagement in everyday routines is a powerful progress in one domain of performance has apredictor of developmental growth (McWilliam, et al, minimal impact on other domains (Lovaas, 1987;2009; Strain & Schwartz, 2009). That is, when young National Research Council, 2001; Strain & Hoyson,children are actively and appropriately engaged, one 2001). This widely replicated finding necessitates an Early Intervention Colorado Autism Guidelines for Infants and Toddlers 7
  • 12. approach to IFSP design that addresses all relevant starting something new and different. During thedomains of performance for children receiving early transition to a school-based program at age three,intervention services. there are changes in adults, children, settings, and routines. Children with ASD may be so sensitive toFactor 5. change as to notice differences that others do not.Data-based decision-making. As has been emphasized There are significant differences between theelsewhere in this guidance document, a key component service delivery model used in the earlyto effective early intervention is to install a data intervention program and that of a programmonitoring system and related decision-making developed by a local school district for specialstrategies to optimize the delivery of effective services. education services. Planning and flexibility on theIn considering all five factors, one might pose that part of early intervention providers and preschoolthe formula associated with quality outcomes is programs are necessary to assist families andactually multiplicative. That is, the formula is as young children with adjusting to this change.follows: When planning the transition from an early(Intensity) x (Fidelity) x (Social Validity) x intervention program at age three years to a(Comprehensiveness) x (Data-Based Decision-Making) = preschool educational program, the following areQuality Outcomes helpful:In this formula, the fundamental message is that asany factor approaches a “zero value” then the sum or 1. The earliest possible referral, with parent consent,outcome will approach zero as well! The formula also to the local school district for a preschool (Part B)suggests that for many infants and toddlers with ASD evaluation;the resulting plan may well involve a large number of 2. The earliest possible communication, with parenthours of direct service. The key difference is that the consent, to the school district about the strengthsnumber of hours should be the product of a carefully and needs of the child and family;designed IFSP and not determined arbitrarily. As 3. Details of the early intervention service(s) that arementioned earlier related to Factor 1 (Intensity), the in place and strategies that have been successful;ultimate number of hours must be sensitive to the anddevelopmental availability of infants and toddlers ingeneral to engage in instructional episodes. 4. A focus on supporting the family, as well as theRelatedly, research by Dunst and colleagues suggest child, throughout the transition process.that IFSPs that result in families having a narrow and Unfortunately, many young children with ASD dosole focus on getting the maximum amount of not present their complex needs until very shortlyintervention may have harmful effects on both family before their third birthday. If that is the case, earlyfunctioning and on ultimate child outcomes (Dunst, intervention providers must work diligently to helpTrivette & Hamby, 2007). parents understand the need to share information with the school district as soon as possible.Implementation of these guidelines will ensure that Transition and transition activities should be amore and more infants and toddlers and their major focus of IFSPs for all toddlers with ASD,families affected by ASD will achieve the quality especially for those nearing the age of three.outcomes they desire and deserve. Similarly, cooperation between the early intervention program and the school district is■ Principle 12: essential for effective transitions. Prior to theThe transition from the early intervention transition conference meeting, it may be helpful toprogram to preschool special education and identify skills that can be introduced at home butrelated services should be well planned. that will be helpful in a school-based program. In addition, community resources for necessaryToddlers with ASD often have difficulty with family supports should be identified that may notchange, including change experienced when be available from the school.8 Early Intervention Colorado
  • 13. Detailed Guidance for KeyPractice IssuesThe following sections offer a wide variety of both moving the services into the child’s naturalconceptual and practical strategies that providers and environment;families can use to help guide the development, 6. When services will be scheduled and coordinateddelivery and monitoring of IFSPs for infants and to achieve targeted outcomes;toddlers with ASD. 7. Number of visits or sessions the child will receiveStrategies For Designing IFSPs for each service and how long each will last;The IFSP is a process that uses a written plan to: a) 8. Whether the service will be provided one-on-one,document current levels of development, b) identify in an inclusive community setting or throughfunctional learning objectives for the identified child consultation with a caregiver or provider;and family, and c) specify early intervention services 9. Who will pay for the services;needed by the eligible child and family. The IFSP 10.Name of the service coordinator overseeing theprocess is directed by and developed jointly with the implementation of the IFSP;family, other individuals of the family’s choice,members of the assessment team, the service 11.Steps to be taken to support the child’s transitioncoordinator and appropriate early intervention service out of the early intervention program and intoproviders. While the general process for the another program when the time comes;development of an IFSP is well documented in the 12.The IFSP may also identify other services theEarly Intervention Colorado policies and procedures, family needs, but are not required under Part Cas well as information for families, (see A Family of IDEA;Guidebook, Guide II: The Individualized Family 13.The IFSP needs to be reviewed, and updated ifService Plan and Orientation to Early Intervention appropriate, at least every six months and isServices at www.eicolorado.org), the following rewritten annually;bullets describe some key ingredients that shouldcharacterize all IFSPs: 14.The IFSP must be fully explained to the parents, and their suggestions must be considered; and1. Family information, including their resources, concerns and priorities for their child as identified 15.The parent must give written consent before by the parents through interviews, assessments services can start. and informal contacts with the service Creating an IFSP that meets the needs of infants and coordinator, early care and education staff, toddlers and families affected by ASD is, in many doctors, nurses and other family members; cases, a complex and evolving process. The available2. The child’s present physical, cognitive, research base for early intervention service delivery communication, social emotional, and adaptive to infants and toddlers with ASD is quite limited. The development levels and needs, obtained from a evidence-based practices are evolving as early multidisciplinary evaluation; intervention providers and researchers use ongoing data systems to guide the developing body of3. Functional outcomes expected to be achieved for knowledge about how to determine what services, the child and family in the following six months methodologies, intensities and frequencies yield and the strategies to meet those outcomes; meaningful behavioral change in young children4. Specific services the child will be receiving; under the age of three years.5. Where the services will be provided within the In the absence of definitive research on child’s natural environments (e.g., home, interventions for children under age three, it is childcare). If the services will not be provided in recommended that IFSP teams ask themselves the the natural environment, the IFSP must include a following questions to guide the IFSP planning statement justifying why not and strategies for process for infants and toddlers with ASD in order Early Intervention Colorado Autism Guidelines for Infants and Toddlers 9
  • 14. to support the delivery of services that are Question 5.individualized, evidence-based and Is there a plan in place to use a primary providercomprehensive (this list is also provided in service model or, where multiple providers are seeingAppendix A for teams to use): the child, a plan to meet frequently to communicate, plan logically consistent services and reviewQuestion 1. progress?Have assessment strategies been utilized todocument the child and family needs identified in the Question 6.IFSP that are: Do the planned strategies include ongoing data collection (see section on “Monitoring Progress”a) Specific (observable, measurable, and valued by pp. 34–36) and clear decision-making guidelines family members)? regarding the continuation or modification of theb) Functional (related to specific skills that help the plan that results in progress for meeting child and child access everyday life)? family outcomes?Question 2. Together, the practice principles discussed in theAre there evidence-based strategies in place on the previous section with the straightforward answers toIFSP that: these questions will help to ensure that IFSPs area) Address each area of need identified by the team? sufficiently comprehensive, designed to produce functional outcomes in essential real world settings,b) Match functional outcomes that include are utilizing evidence-based practices, and are addressing the defining characteristics of ASD delivered in a competent, coordinated and data-based (communication, social skills, and behavioral fashion. In order to maximize the child’s skill concerns)? generalization across persons, settings and time, it isc) Specifically address the child and family being essential to first consider the child’s planned learning successful with daily routines (e.g., dressing, opportunities delivered by adult family members feeding, bedtime, community outings, etc.)? and/or adults in other inclusive community settingsd) Include strategies to equip family members with prior to determining the number of direct service the information and skills needed to provide hours on the IFSP. consistency in intervention when early For children with ASD, we suggest the use of two intervention providers are not present? tools to help parents identify and communicate theQuestion 3. current levels of functioning for their children duringHas the IFSP team carefully considered the following everyday experiences at home and in the community.questions, taking into account the child’s One example is the About Our Child assessment tool,developmental availability for intervention and the (Strain, 2002) (see “Appendix B”) that aids parents orfamily’s dynamics and available resources: other caregivers in identifying skills their children currently demonstrate in common everyday activitiesa) What early intervention services are needed to and routines. Additionally, the tool helps to identify implement the evidence-based practices? skills that parents would like their children to learn inb) Who will deliver the services? these areas. The About Our Child document starts byc) Where the services will be provided? asking parents or other caregivers to list what the child can do in the following areas:d) When and how frequently the services will occur?e) What available funding sources will be accessed? a) Play—Skills such as appropriate toy play, sharing, taking turns, playing by themselvesQuestion 4. (independence) and playing with other children.Are the proposed providers fluent with the evidence-based practices to be delivered? If not, what plans b) Language—Includes skills such asare in place to provide training, supervision or communicating wants and needs, followingcoaching for those providers? directions, listening skills, understanding concepts (e.g., in, on, up, etc.).10 Early Intervention Colorado
  • 15. c) Adaptive—Skills such as dressing, hand washing process and helps determine what skills or behaviors and toileting. a child must learn to be successful in daily routines.d) Meal Time—Skills such as eating with utensils, This protocol is an excellent supplement to About eating a variety of foods, using a cup and sitting Our Child as it more directly pinpoints the daily at the table for meals. routines that will serve as the context for service delivery. Further description of the RBI can be founde) Bath Time—Skills such as sitting in the tub, at www.siskin.org/www/docs/112.190. washing body parts, brushing teeth, combing hair.f) Cognitive—Includes skills such as understanding A Tiered Model For Thinking About Specific simple stories, identifying pictures of objects, Needed Early Intervention Services letters and numbers, shapes, colors, matching This section of guidance provides the reader with a and sorting. general approach for building a set of IFSP servicesg) Motor—Covers gross motor skills like running based on a thorough review of needs and and jumping, rolling, catching and throwing a ball preferences. One of the great challenges in the early and fine motor skills including opening intervention field is the brief time period available for containers, turning door knobs, holding crayons the delivery of services to infants and toddlers with and markers, using scissors and playing with ASD. Even in the best case, it is likely that IFSPs will material like play dough. be in place for no more than 18 months, and many will be in place for much shorter periods of time. Inh) Community Activities—Skills such as sitting in a such a “time-critical” circumstance, it is essential cart at the grocery store, riding in a stroller, that services are optimized to yield the most playing at a playground and riding in the car. functional and powerful outcomes in a context wherei) Behavior—Behaviors that interfere with learning, public resources are scarce. It is in this complex that the parents would like their child to do less context that the following model is offered as a often, are aggressive, self injurious or deal with general guide for conceptualizing and planning early sensory sensitivities. intervention services.After parents have a chance to list the skills the child The tiered model being advanced for infants anddemonstrates across these areas they are asked to list toddlers with ASD is based on the three-level modelnew skills they would like their child to learn in each of of prevention that has been increasingly common inthese areas. Because parents spend time with their many arenas of social services, including publicchild doing these things on a daily basis it can provide health and education (e.g., Fox, Dunlap, Hemmeter,assessment teams valuable information regarding the Joseph, & Strain, 2003; Simeonsson, 1991; Sugai etchild’s functional skill set throughout the day which al., 2000; Walker et al., 1996). The model begins bycan be used alongside any additional formal or defining target behaviors in need of prevention, suchinformal assessments the team has conducted. Ideas as social isolation, destructive/disruptive behaviorsgenerated through the About Our Child can be shaped by infants and toddlers with ASD, or high levels ofdirectly into goals and/or objectives on the IFSP. parental stress. Strategies intended to prevent theMoreover, the form is a good starting place for occurrence or further development of the targetbuilding an intervention that is contextually relevant to behaviors are then categorized along a hierarchythe everyday activities that the family experiences. The related to the proportion of the population for whomform may be completed by the parents or other the strategy would be pertinent, the intensity of thecaregivers themselves or the service coordinator or strategy and in terms of the stage of the targetprovider may gather this information through an behavior’s development.interview process with the family. Level 1 Strategies:A second recommended tool to gather family Building Positive Relationships, Supportiveinformation is through the use of the Routines-Based Environments, and Healthy PhysiologiesInterview(RBI) (McWilliam, 1992, 2005, 2008). The Level 1 strategies are intended for the entireRBI is a part of a functional intervention planning population of infants and toddlers and families Early Intervention Colorado Autism Guidelines for Infants and Toddlers 11
  • 16. affected by ASD or challenging behaviors. The intensive and costly than Level 3 strategies. Still, forstrategies are geared to an early stage of prevention infants and toddlers with ASD, due to their substantialand are relatively inexpensive and easy to implement. risk factors, it is likely that a relatively large segmentThis level is referred to as primary prevention, of the population will require and benefit from Level 2involving universal applications. For example, a strategies. Level 2 strategies, to a large extent, areuniversal strategy for the prevention of disruptive based in the science of Applied Behavior Analysisbehavior might include establishing a functional (ABA) (Baer, Wolf & Risley, 1968). Examples ofsystem of communication, especially one by which additional Level 2 strategies include using naturalisticthe individual can readily express wants, needs and teaching strategies like incidental teaching, Pivotalirritants. A universal strategy to prevent parent stress Response Training and modeling to teach appropriatethat interferes with the child’s development might play skills, increasing engagement and motivation,include guided opportunities for family members to using antecedent prompting to prevent challengingdiscuss issues they face with others in similar behaviors, discrete trial instruction and the utilizationcircumstances. Universal strategies for infants and of peer-mediated interventions.toddlers with ASD would be implemented for all Level 3 Strategies:children and families, as early as possible. Additional Individualized Intensive Interventionsexamples of Level 1 strategies include building Level 3 is for infants and toddlers and their familiesstrong parent–child relationships, including a focus who are already displaying the target behaviors andon joint attention, environmental organization, the require relatively intensive and individualizeduse of visual schedules and ensuring sound physical interventions. This level is referred to as tertiaryhealth for the infant or toddler. prevention, with individualized, intensive interventionLevel 2 Strategies: procedures. Level 3 involves individualizedBuilding Social and Communicative Competencies assessment and assessment-based interventions thatInconsistent with Problem Behavior are relatively well-represented in the current literatureLevel 2 is referred to as secondary prevention, and is on PBIS and ABA. Level 3 also assumes thatintended for young children for whom Level 1 is providers will work, in part, with an individual infantinsufficient and who are clearly at risk for, or who are or toddler and his or her family on a one-to-onealready demonstrating, early indications of the basis. These strategies are markedly more expensivenegative target behaviors. For infants and toddlers in terms of resources and time required than Levels 1with ASD, Level 2 might include specific procedures or 2. It is important to clarify that Level 3 is not justdesigned to teach appropriate problem solving, self one level of intensity. It is actually a set of proceduresregulation and coping, and to divert them from using on a continuum of intensity that is based on theproblem behavior. An example of a Level 2 strategy extent to which challenges are severe, long-lasting,for a two year-old who has as an objective to wait for and demonstrably resistant to change. For example, ifthree seconds before accessing a requested item a toddler is beginning to display tantrums at home,would be the use of a large size visual and auditory but the tantrums are limited to one or two dailytimer. Once the timer signals the end of a three- occurrences (i.e., seeking attention at mealtimes) andsecond interval, the mother can grant access to the have not been exhibited in the community or otherrequested item. This could be done during simple settings, then the procedures need not be as timehome routines, such as the toddler and another consuming or especially effortful (though they mayfamily member (a sibling, the father, and aunt) taking still require individualized assessment and anturns to request a favorite snack item and waiting for individualized intervention plan) (Dunlap & Fox,three seconds for its delivery. 1999; Strain & Schwartz, 2009). On the other hand, if a child has demonstrated severe problem behaviorsLevel 2 strategies to prevent parental stress might for several months, and the problems have persistedinclude systematic, group-based training in strategies in many environments despite multiple efforts atthat make daily routines more enjoyable. Level 2 remediation, then the Level 3 process is likely tostrategies are more focused than Level 1, involve a require a considerable investment of time andsmaller proportion of the population, and are less resources to be effective.12 Early Intervention Colorado
  • 17. LEVEL 3: Individualized Intensive Interventions LEVEL 2: Building social and communicative competencies inconsistent with problem behavior LEVEL 1: Building positive relationships, supportive environments, and healthy physiologiesFigure 1. Tiered Intervention Model for Children with Autism Spectrum DisordersThe multi-tiered prevention model is represented in typically developing child. Therefore, it is importantFigure 1. The bottom tier, Level 1, is intended for all to take concerted measures to reduce potentialinfants and toddlers with ASD and other young irritants and to teach the child, from a very early age,children with severe communication and/or that interacting with the social environment isbehavioral delays, while Levels 2 and 3 build pleasurable and satisfying. Level 1 strategies areincreasingly focused and intensive supports for those geared to all children with a diagnosis or likelyinfants and toddlers who demonstrate high risk classification of ASD and they should befactors and needs related to overall development and implemented as soon as possible.problem behaviors. The following descriptions One category of Level 1 strategies involves theprovide further details on of the three levels along development of positive relationships betweenwith examples of intervention strategies. Much parents (and other family members and caregivers)greater detail on evidence-based strategies is and the infant or toddler. The intent is to teach thecontained in the “Evidence-Based Interventions and child that parents and caregivers can be relied on asMeasuring Outcomes” section of these guidelines. stable, secure, and safe figures that provideLevel 1: nurturance, comfort, pleasure and guidance.Strategies for infants and toddlers with Developing attachments is a challenge for an infantAutism Spectrum Disorders. or toddler with ASD, so special efforts are required, even when signs of a child’s interest are notIt is understood that infants and toddlers with ASD apparent. This might require that a parent orhave more difficulties interacting with and managing caregiver identify the activities, objects, settings, andtheir environments than young children who are interactions that the child finds pleasurable andtypically developing. As a result, there are provide those events and items to the childundoubtedly more events and circumstances in the contingent on a social interaction behavior (ratherenvironment (including the child’s physiological than non-contingently in a manner meant to keep aenvironment) that can be irritants to the child, and child satisfied without social interaction). Forwhich cannot be resolved as efficiently as with a example, a tickle game might be initiated with a child Early Intervention Colorado Autism Guidelines for Infants and Toddlers 13
  • 18. and then interrupted by the caregiver with the that the child communicate or socially interact can beexpectation that the child look at the adult or repeat a detrimental to the child’s potential for developing agesture to continue. A key objective of efforts to form repertoire of social and communication skills.positive relationships is to ensure that the Third, a key category of Level 1 strategies involvesinteractions are pleasurable and that they are procedures to insure that the child’s physical healthassociated with the child receiving input that is is sound, that somatic complaints are understoodconsistent with needs and interests. Importantly, and addressed, that the child has daily opportunitiessuccessful efforts to form strong, positive bonds for vigorous exercise (e.g., Kern, Koegel, & Dunlap,when a child is very young result in a subsequent 1984), and that the child consumes food andrelationship in which an adult has considerable beverages that are nutritious. A child’s physiologicalinfluence over a child’s behavior, and this influence well being is an important factor in preventing thecan be essential for the guidance and instruction that emergence of problem behaviors as it is likely thatthe adult (parent or other caregiver) must provide on some problem behaviors begin as simplean ongoing basis. expressions of internal discomfort (e.g., cryingA second category of Level 1 strategies involves the elicited by a stomachache) which are thenprovision of a safe, comprehensible, stimulating and inadvertently shaped by external contingencies (e.g.,responsive environment. As a young child with ASD provision of attention) into full-fledged problemoften has difficulty navigating their surroundings, it is behaviors (e.g., violent tantrums). The relationshipuseful to be sure that clear physical cues are between physiological circumstances and problemconsistently available to help a child locate desired behavior has not been studied extensively, howeveritems and to make appropriate requests. The there is no doubt the link is a powerful one and thatunderstanding of the environment, schedule, and improved medical assessment and care can be arequests is often enhanced through the use of visual powerful Level 1 strategy of prevention (Carr &supports or object cues that provide the child with Owen-DeSchryver, 2007).additional information on what is expected (e.g., And, finally, Level 1 also includes intentionalDettmer, Simpson, Myles, & Ganz, 2000; Olley & instruction to help infants and toddlers acquireReeve, 1997). Similarly, toys and other objects of functional communication skills needed to effectivelyinterest should be available, especially of the type and conventionally control aspects of thethat occasion social interaction. For example, books environment. For example, even when a child has noprovide an excellent opportunity for turn-taking other distinguishable language, parents can help aexchanges and exposure to print language. Other toddler with ASD to use vocalizations or gestures totoys, such as balls, blocks, and art materials are request or reject objects and activities, and they caneasily used to support the child’s motor, cognitive, help build communication exchanges by respondingand social development. In addition, the environment to the child’s nonverbal expressions as comments orshould be set up so that a child’s initiations are met requests for information. A young child’swith appropriate responses, along with guidance and communicative competence is one of the mostsupport to sustain interactions and help insure that salient factors related to the extent that the child withthe child’s motivations are fulfilled. A correlate of this ASD develop social relationships and achieve desiredcategory is that a child with ASD should be exposed lifestyle outcomes (Woods & Wetherby, 2003). Ato a variety of community and social contexts, while focus on the development of communication andbeing supported by assistance and positive guidance language skills should include an emphasis on theto insure that these experiences are enjoyable and forms of communication (e.g., from using gesturessuccessful for the child. The active engagement of to words) as well as the pragmatics ofthe child within meaningful activities and social communication (e.g., the social process ofinteractions is pivotal to the child’s overall communication) including initiating interactions,development and ability to navigate social establishing joint attention, and maintaining aenvironments (Kohler & Strain, 1992). Thus, the conversation. For the child with ASD, it is necessarypervasive use of passive activities (e.g., watching to pursue this kind of instruction intentionally andvideos, playing alone repetitively) that do not require14 Early Intervention Colorado
  • 19. deliberately and, always, with awareness of what the peers. They illustrate such environments withinstruction does to help the child be an active reference to two model programs: LEAP (Learningparticipant and, to some extent, manager of his or Experiences: An Alternative Program), developed byher surroundings. Strain, and Project DATA, developed by Schwartz. Embedded within the programs’ structure andIn addition to the instruction of communication skills, curricula are Level 2 strategies designed to buildthe toddler with ASD most likely needs explicit skills and simultaneously reduce the probability ofinstruction and support to meet other developmental problem behaviors. One strategy is an “appropriatemilestones, including self-care skills (e.g., assisting engagement strategy” in which the procedural focuswith dressing or toileting), play skills, independence, is on increasing children’s appropriate engagementand some motor skills (e.g., using a crayon or a with materials and activities. Although not designedspoon). The promotion of the toddler’s overall skill explicitly as an intervention for problem behaviors,development often requires repeated, intentional, increases in engagement tend to be related toinstructional episodes and the provision of reduced occurrences of problem behavior and, thus,systematic prompting and encouragement to assist the engagement serves as a strategy for preventingthe child in achieving independence. problems without an intensive behavior interventionLevel 2: plan (Kohler & Strain, 1992; Dunlap & Strain, 2009).Strategies for infants and toddlers with For example, for a child who wanders around theAutism Spectrum Disorders. home, climbs on furniture or dumps out baskets of toys, teaching simple play skills like building withWhile Level 1 strategies involve the provision of blocks, pushing cars or doing puzzles not onlyexperiences and supports that are reasonable for any increases appropriate engagement, but also likelyinfant or toddler, regardless of the child’s abilities and decreases the amount of time the child spends in thechallenges (though strategies for infants and toddlers inappropriate behaviors listed above.with ASD may require more intentional effort on thepart of the parents or caregivers), Level 2 strategies Level 2 strategies are also found in manyinvolve specific procedures designed to enhance a comprehensive programs for helping young childrenyoung child’s behavioral competencies and, with ASD (e.g., Koegel & Koegel, 2006; Mahoney &indirectly, help prevent the development or display of Perales, 2003). Such strategies are oftenproblem behaviors. Level 2 is for infants and toddlers components of the larger program that can bewith ASD for whom Level 1 is insufficient and who implemented in home and community contexts,have risk factors that indicate a need for more whether or not the comprehensive program isdeliberate strategies. Such risk factors include available. For instance, Pivotal Response Treatmentsobvious delays in language development, notable (PRT) (Koegel & Koegel, 2006) is a unified andavoidance of social interactions, and a failure to comprehensive approach to intervention for childrenacquire functional skills. These criteria suggest that a with ASD. Included within the program are numerouslarge proportion of infants and toddlers with ASD procedures that are useful for increasing themay require Level 2 supports, and that is indeed the motivation and engagement of children with ASD,case, though the actual proportions are unknown and and such variables serve not only to enhancemust await the completion of considerable research. children’s cognitive, communicative and social development, they also serve to prevent problemStrain and Schwartz (2009) provide examples of behaviors. Examples of such procedures includeLevel 2 strategies for preventing the development of following the child’s lead, using preferred items orproblem behaviors in the repertoires of infants and activities, providing clear instructions, teachingtoddlers with ASD. These authors note, first of all, within natural contexts, providing choices, discretethat a primary consideration of programs for young trial instruction, reinforcing the child’s attempts,children with ASD is to provide an environment that varying and interspersing tasks, and using naturallyis designed to prevent problem behaviors, promote occurring reinforcers (Koegel & Koegel, 2006). Inengagement and participation, and facilitate addition to PRT, other related evidence-basedsuccessful interactions with typically developing strategies include incidental teaching (McGee, Daly & Early Intervention Colorado Autism Guidelines for Infants and Toddlers 15
  • 20. Morrier, 1999), modeling, various antecedent Implications for Implementationprompting tactics, and peer-mediated intervention The 3-tiered model carries two major implications for(see modeling on page 22). Such procedures involve practice. The first is that an early and concertedless effort and intensity than Level 3 strategies, yet emphasis on preventive strategies has the potentialthey can be extremely useful for promoting to influence a child’s development in the direction ofcommunication, social and cognitive development more pro-social behaviors and a lower likelihood ofand preventing the development of problem severe problem behaviors. It is reasonable to assumebehaviors. Please see “Evidence-Based Interventions that a proportion of infants and toddlers with ASDand Measuring Outcomes” section of these who eventually come to develop problem behaviorsguidelines for more detailed descriptions of Level 2 might be diverted from this negative trajectory ifinterventions. Level 1 and Level 2 strategies are implemented earlyLevel 3: enough and with sufficient intensity and consistencyStrategies for infants and toddlers with (Dunlap, Johnson, & Robbins, 1990; Strain &Autism Spectrum Disorders. Schwartz, 2009). Therefore, a major implication of the model is that much greater consideration shouldLevel 3 strategies are comprised of procedures that be given to Level 1 strategies such as healthcare, theare most readily associated with problem behavior provision of stimulating and enjoyable environments,interventions because these are the strategies that and supported participation in complex socialare implemented after problem behaviors have contexts. Supporting families to gain knowledge anddeveloped to the point that they have become skills of Level 1 strategies is critical to the ongoingacknowledged obstacles to early learning and healthy support they can provide to their children throughoutsocial emotional development, and when they their early childhood development and beyond.present threats to the physical and emotional safetyof the infant or toddler with ASD, peers or others in A second important implication of the model is that,the vicinity. even for infants and toddlers with very severe disabilities and prominent risk factors (e.g., anAt one time the predominant approach for problem absence of functional, conventional communicationbehaviors was based almost entirely on contingency skills), a solid foundation of Level 1 and Level 2management, in which interventions consisted of strategies should reduce the need for more labormanipulations of reinforcers and punishers. While intensive interventions at the tertiary level. Forcontingency management is still important, Level 3 infants and toddlers with ASD and their families,strategies have broadened considerably over the past the fundamental issue is that implementing Level 1two decades and now include a focus on and Level 2 strategies does not simply lessen therearrangements of the antecedent environment and need for more intensive supports, it often preventsinstruction on functional alternatives to the problem the onset of challenging behaviors, prevents adultbehaviors. Level 3 strategies now place a strong stress, and improves developmental functioning inemphasis on prevention rather than suppression. In key areas of communication and social skills. Theaddition, Level 3 interventions are generally preceded significance of this cannot be overstated. That is,by a process of functional assessment, designed to even if Level 3 strategies are needed, the presence ofidentify intervention components that address the Level 1 and Level 2 procedures will reduce the effortindividualized functions of the particular child’s associated with the Level 3 interventions that areproblem behaviors. The overall process of required to effectively address existing needs.assessment and intervention is commonly referred toas “positive behavioral interventions and supports”(PBIS) (Carr et al., 2002).16 Early Intervention Colorado
  • 21. Evidence-Based Interventionsand Measuring OutcomesWhile the Tiered Intervention Model for Children with Established Interventions in theAutism Spectrum Disorders offers teams a way of National Standards Projectconceptualizing services in general, this section Details regarding the NSP methodology forprovides an overview of very specific, evidence-based identifying interventions and rating them can bepractices that can fit within the conceptual model. found online through the National Autism Center’sThere are literally hundreds of intervention methods website at www.nationalautismcenter.org/that have been used to improve the core symptoms affiliates/. Eleven interventions were identified asof ASD. Some methods are highly effective, some “Established” (i.e., they were established as effective)less so, still others are ineffective. What seems for individuals with ASD. Established Interventionscertain is that regardless of demonstrated are those for which several well-controlled studieseffectiveness, many methods are vigorously showed the intervention to produce beneficial effects.marketed to providers and families. The guiding There is compelling scientific evidence to show theseprinciple that children and families should be interventions are effective; however, even amongprovided with evidence-based practices has led Established Interventions, universal improvementsdirectly to the following set of recommendations cannot be expected to occur for all individual childrenbased upon the National Autism Center’s National with ASD. The NSP also categorized otherStandards Project (NSP) (2009). Moreover, these interventions as “emerging” (i.e., some tentativepractices are also in line with those recommended by evidence of effectiveness) or “un-established” (i.e.,the National Professional Development Center on no data upon which to recommend use).ASD (2009). The eleven Established Interventions identified byThe NSP, by far the most comprehensive and NSP include:rigorous review of the scientific literature on children 1. Antecedent Package (Prompting)with ASD to date, was designed with three purposes 2. Behavior Package (Discrete Trial Training andin mind: Positive Behavioral Interventions and Supports)1. To identify the level of research support currently 3. Comprehensive Behavioral Treatment for Young available for educational and behavioral Children with Autism interventions used with persons with ASD. Knowing levels of research support is an 4. Joint Attention Intervention important component in selecting interventions 5. Modeling that are appropriate for individuals on the autism 6. Naturalistic Teaching Strategies (e.g., Incidental spectrum. Teaching)2. To help parents, caregivers, educators, and 7. Peer Training Package service providers understand how to integrate critical information in making intervention 8. Pivotal Response Treatments decisions. Specifically, evidence-based practice 9. Schedules involves the integration of research findings with 10.Self-management a) professional judgment and data-based clinical decision-making, b) values and preferences of 11.Story-based Intervention Package families, and c) assessing and improving the For information on other levels of effectiveness see capacity of the system to implement the the full NSP report at www.nationalautismcenter.org/ intervention with a high degree of accuracy. affiliates/model.php.3. To identify limitations of the existing treatment Self-management and Story-based interventions, research involving persons with ASD. which rely on complex language and cognitive skills Early Intervention Colorado Autism Guidelines for Infants and Toddlers 17
  • 22. are not included in these guidelines, as they will likely verbal or physical prompts to the child to help him ornot be used for many children under the age of three her engage in desired behaviors. It is important toyears. However, given the heterogeneity of ASD, give the correct amount of prompting to ensure apractitioners may reasonably consider these correct response, ensuring the child does not learnintervention methods for toddlers who are high- and practice errors. Three of these widely usedfunctioning. Comprehensive Behavioral Treatment strategies are most-to-least prompting, least-to-mostwas also excluded from the detailed interventions that prompting, and using time-delays during prompting.follow. The literature from which this category was A. Most-to-Least Promptingderived is based solely upon enrollment of childrenwith ASD in research-based behavioral intervention This involves the adult initially using the most amount ofprograms that are not generally available. Additionally, prompting necessary for the child to perform a correctamong all these comprehensive programs there are response. The prompts themselves can be full physicalno unique individual interventions that are not prompts, such as hand-on-hand guidance (such ascovered by the remaining discrete interventions that pointing to a picture), or physically moving body partsare recommended herein. (such as opening the kitchen cupboard). As the child demonstrates proficiency in the behavior/response, theOne “emerging” strategy is included—Augmentative prompts are faded and the physical guidance isand Alternative Communication. Since many children reduced. For instance, instead of hand-on-handwith ASD in this age range do not yet have functional prompting, the child may, over time, only require a lightspeech, it is very likely that these non-verbal touch on the arm. Typically, most-to-least promptscommunication systems will be needed. begin with physical guidance, move to visual prompts,Nine Recommended Strategies for such as showing a child a picture of the kitchenInfants and Toddlers cupboard as a prompt to open it, to verbal instructions, such as, “open the cupboard,” to natural cues in theWhile the wide diversity and unique needs of infants environment, such as the child opening the cupboardand toddlers with ASD must always be considered, when the parent tells the child, “breakfast time!”the nine recommended interventions detailed belowrepresent a wide range of strategies sufficient to B. Least-to-Most Promptingaddress all the core symptoms of autism in young This procedure is the opposite of most-to-least, andchildren. Importantly, these interventions have been begins with the adult giving the child the opportunity toimplemented successfully by a broad range of respond with the least amount of prompting. Theproviders, families and in some cases, other children. amount of prompting by the adult increases with eachThe recommendation is that teams become proficient behavior/response that the child fails to perform orat delivering these interventions, plan on delivering performs incorrectly. For instance, if the child does notthese interventions first, and then examine “emerging open the kitchen cupboard three seconds after the parentintervention options” only after data indicate less says “breakfast time!” she can start prompting by sayingthan desired outcomes using these interventions. “breakfast time!” again, and then verbally ask the child to open the cupboard. Least-to-most prompting beginsThe Nine Recommended Interventions: with using natural environmental cues, then proceeds toDescription and Application using verbal instructions, possibly with an additionalBelow is a general description of the nine visual cue (picture, gesture or modeling), and then torecommended interventions, their implementation for partial physical and full physical prompting.infants and toddlers with ASD and readings that offer C. Time-Delaymore procedural detail. Following this generaldescription are examples of intervention use with three Time-delays can be used as part of these antecedentcase studies of infants and toddlers and their families. prompting procedures by varying the time interval between the initial prompt for the child to give a1. Antecedent Package (Prompting). response/behavior and the subsequent promptingAntecedent (before) prompting (cues, support, or given by the parent if the child does not respondhints) is a group of strategies in which the adult gives correctly. See figure 2:18 Early Intervention Colorado
  • 23. Figure 2 TIME-DELAY of 3 seconds before parent prompt Time 9:00:20 Time 9:00:23 Parent says Parent says “Breakfast time, Ally” “Breakfast time, Ally” & physically prompts cupboard opening Ally does NOT open the kitchen cupboard (no response) end, thereby, being ‘discrete’ and is depicted in figure Where to Get More Information on Antecedent Package 3: (Cooper, Heron, & Heward, 2007). Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied Behavior Analysis. New Jersey: Prentice Hall. Key elements of using DTT to teach young children Fein, D., & Dunn, M. A. (2007). Autism In Your with ASD include breaking skills into small chunks Classroom. Bethesda: Woodbine House. (behaviors) so each chunk can be taught directly and Dunlap, G., Iovannone, R., Kincaid, D., Wilson, K., learned to mastery before chaining the behaviors Christiansen, K., Strain, P., & English, C. (2010). together (De Boer, 2007; Fein & Dunn, 2007). In Prevent—teach—reinforce: the school-based model addition, teaching typically involves the use of of individualized positive behavior support. prompting and fading (dependent on child’s needs) Baltimore: Paul Brooks. and there needs to be a rich supply of child-specific reinforcers given (e.g., toys, objects, games)2. Behavioral Intervention Package: contingent on the child’s responses. Behaviors can be shaped dependent on the speed and value of theA. Discrete Trial Training reinforcers after a response (Alberto & Troutman,Discrete Trial Training (DTT) is a structured teaching 1999; Cooper et al., 2007). For instance, an easy orstrategy that involves distinct and repetitive mastered response can be reinforced with a low-responses following a specific stimulus, and preferred reinforcer such as a “high five!” whereas aresulting in reinforcement. Each trial is typically new and difficult response can be reinforced with adefined as (A) Antecedent, (B) Behavior, and (C) high-preference reinforcer such as jumping on aConsequence, and has a definitive beginning and trampoline or swinging on a swing.Figure 3 A Complete Discrete Trial A = Antecedent B = Behavior C = Consequence Beginning Middle End • A question • An answer • A reinforcer (e.g., toy, praise) • A command • A behavior • Teacher’s reaction to response • An instruction • A response • A Discriminative Stimulus SD “Yay, right answer, here is “What color is this truck?” “Blue” your toy” (gives toy to child) Early Intervention Colorado Autism Guidelines for Infants and Toddlers 19
  • 24. The prompting procedures used in DTT can be to include at least one member with knowledge andphysical and/or verbal, such as holding and experience with ABA and PBIS.manipulating a child’s hands to demonstrate clapping, An initial responsibility of the team is to gainor saying “it’s red” after being shown a red car and consensus on the child’s strengths and challengesasked “what color?” (De Boer, 2007; Fein & Dunn, and to form agreement on immediate goals for2007; Vargas, 2009). Prompting procedures are very intervention, as well as a vision for the child’simportant in DTT as the child should always be accomplishments over the coming one to threeprompted to give the correct response, also known as years. Routines-based interviewing is a process thaterrorless learning. Errorless learning contributes to a has proven to be very useful for achieving this kind ofpositive learning environment, prevents the child from unified vision (McWilliam, 2009).performing and practicing errors, and may reduce achild’s frustration (De Boer, 2007; Vargas, 2009). As 2. Conducting a functional assessment of problemDTT is highly structured and some young children behavior. The next step is to use procedures ofwith ASD may display avoidance or escape behaviors functional assessment to gain an understanding ofto this type of learning environment, the adult should how the targeted problem behavior(s) are governeduse positive pairing, so he or she is viewed by the by events and circumstances in the environment.child as a reinforcer. Positive pairing can be achieved There are numerous books and manuals that specifyby engaging in preferred activities with the child or the particulars of the functional assessment processbeing the source of obtaining what the child wants or (e.g., O’Neill et al., 1997), but they generally boilenjoys (reinforcer) (De Boer, 2007). down to direct observational and indirect interview methods for answering core questions, such as: Where to Get More Information on Discrete Trial Training a) What is the function or purpose of the problem Alberto, P. A., & Troutman, A. C. (1999). Applied Behavior behavior? Analysis for Teachers. New Jersey: Prentice Hall. b) Under what specific circumstances is the problem Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied Behavior Analysis. New Jersey: Prentice Hall. behavior most likely to occur; and De Boer, S. R. (2007). How To Do Discrete Trial c) Under what specific circumstances is the problem Training. Austin, TX: PRO-ED. behavior least likely to occur? Fein, D., & Dunn, M. A. (2007). Autism In Your Answers to these questions should help team members Classroom. Bethesda: Woodbine House. identify effective and efficient components for a PBIS Vargas, J. S. (2009). Behavior Analysis for Effective plan. These answers, as well as information gleaned Teaching. New York: Routledge. from the goal setting and person centered planning processes, are used to construct the plan. TeamB. Positive Behavioral Interventions and Supports (PBIS). members provide vital input related to their willingness and ability to carry out potential interventionThe five essential elements of PBIS are described below. components. Components are generally selected from1. Establishing a PBIS team (which may be some or procedures that have been demonstrated previously toall of the IFSP team members) and gaining a unified be effective in similar situations.understanding of the child and an agreement on the 3. Designing the PBIS Plan. The plan often includesshort and long-term goals of intervention. For Level components from several categories of strategies.3 interventions, more than one person is generally One of those strategies is antecedent manipulationsrequired for purposes of planning, assessment and that include changes in the stimuli that are found toimplementation. For infants and toddlers, one precede or evoke problem behavior. Such stimuli canmember of this team must be a parent, guardian or be removed or ameliorated, while stimuli associatedkey family member, and other team members also with desirable behavior can be inserted. Teachinginclude childcare providers, early intervention strategies involve identifying functional alternativesproviders from a variety of disciplines, developmental to the problem behavior and arranging for suchintervention assistants, advocates, close friends and, alternatives to be systematically prompted for andas needed, administrators. It is generally a good idea20 Early Intervention Colorado
  • 25. reinforced at times that problem behaviors might each step of the procedure to see if they are beingotherwise occur. Functional communication training implemented correctly or if there is some variation inis a well-established procedure for accomplishing how the child is being prompted.this useful, instructional approach. For example, for 5. Evaluating the effects of the intervention. Thea child that goes to the refrigerator or to a parent document also needs to include a means forand cries when they are hungry, the child is taught a evaluating whether the plan is achieving its intendedfunctional replacement behavior like requesting to effects. Data collection should be:eat by giving a picture card to the parent.Reinforcement strategies involve changes in the a) simple, so that all relevant parties can record datacontingencies that govern the child’s problem without difficulty, andbehavior; in particular, removing reinforcers that b) valid, so that the data truly reflect the changesmaintain the problem and increasing reinforcers for that are the purpose of the intervention.other behaviors. For example, using the scenarioabove, if the parent previously responded to the Simple evaluation tools include rating scales to indicatecrying by giving the child something to eat, a how a session (e.g., a community outing, a regularreinforcement strategy the parent could use is to home routine) rated on a five-point scale ranging from,instead ignore the crying and physically redirect the for example, “very difficult” to “excellent.” The point ischild to get the picture card and give it to them. This that some kind of useful evaluation data needs to bebehavior, giving the picture card to the parent, is collected in order for the team to know if the PBIS planthen reinforced by the parent giving the child is producing benefits as expected, or if adjustments tosomething to eat. The PBIS plan should also include the plan are required. Using the example above, thespecific instructions for the adults who will be child’s overall compliance with following directionsimplementing the plan, including guidance for what could be rated from one to five with a “1” indicating noto do if the problem behavior occurs. directions were followed to a “5” indicating all directions were followed.4. Implementing the PBIS Plan. A key aspect ofimplementation is incorporating procedures to help The strategies described are examples of PBIS whichinsure that the PBIS plan is implemented as have been demonstrated in numerous studies, literatureintended. Intervention agents (siblings, parents, reviews and syntheses to be effective in buildingchildcare provider) often benefit from scripts or desirable skills and reducing or eliminating problemother prompts to cue them about what to do and behaviors (Carr et al., 1999; Dunlap & Carr, 2007). Aswhen. It is also useful to monitor implementation to testimony to its effectiveness, the methods andbe sure that procedures are executed with fidelity, outcomes of PBIS have been described in an immensewhich can be defined as implementing the PBIS plan number of websites, articles, manuals, and books, andor procedures exactly as intended. Then, if data the vast majority of these resources offer informationindicate that anticipated improvements are not and guidance that is evidence-based, credible and useful.occurring, the team can analyze fidelity as onepossible reason for inadequate outcomes. Strategies Where to get more information on Positive Behavioralcan be included to heighten fidelity or the PBIS plan Interventions and Supportscan be adjusted to include components that will be Carr, E.G., & Carlson, J.I. (1993). Reduction of severeeasier to implement. For example, a child’s team is behavior problems in the community using ausing a specific prompting strategy to get the child multicomponent treatment approach. Journal of Applied Behavior Analysis, 26(2), 157–172.to follow a direction. The procedure involves threebasic steps: 1) giving the direction, 2) giving the Dunlap, G., & Fox, L. (1999). A demonstration of behavioral support for young children with autism.direction a second time with an additional visual cue Journal of Positive Behavior Interventions, 1(2), 77–87.or gesture and then, if necessary, 3) giving the Durand, V.M., & Carr, E.G. (1991). Functionaldirection a third time while providing physical communication training to reduce challengingassistance to fully complete the task, and data behavior: maintenance and application in new settings.indicate improvements are not occurring related to Journal of Applied Behavior Analysis, 24(2), 251–264.this behavior. The team may look more closely at Early Intervention Colorado Autism Guidelines for Infants and Toddlers 21
  • 26. 3. Joint Attention. d) Playing with or sharing the focus on a toyJoint attention is a strategy in which a child and a together,parent or another individual engage in mutual interest e) Trying to gain a child/parent’s attention byor show attention to the same object, activity or “catching his or her eye” or gesturing to him orexperience. Joint attention includes a range of her, andbehaviors such as eye gaze and gestures. Themajority of infants and toddlers with ASD do not have f) A child sharing facial expressions with a parent,good joint attention skills. Infants and toddlers with such as smiling or winking.ASD may demonstrate some form of joint attention ifthey are trying to get something they want, such as a Where to get more information on Joint Attentioncookie, but they typically do not seek out another Adamson, L., & Bakeman, R. (1991). The developmentperson for social attention. Generally, a toddler with of shared attention during infancy. In R. Vasta (Ed.), Annals of child development (Vol. 8, pp1–41).ASD will not run up to their dad and show him a London: Jessica Kingsley Publishers, Ltd.picture he or she just drew or want a hug, acts Adamson, L., & Chance, S. E. (1998). Coordinatingtypically seen in children without ASD (Adamson & attention to people, items, and language. In A. M.Bakeman, 1985, 1991; Adamson & Chance, 1998; Wetherby, S. F. Warren, & J. Reichle (Eds.),Brooks & Meltzoff, 2002; Bruner, 1983; Butterworth Transitions in prelinguistic communication (Vol. 7,& Jarrett, 1991; Carpenter, Nagell, & Tomasello 1998; pp.15–37). Baltimore: Paul H. Brookes.Morales, Mundy, & Rojas, 1998; Toth, Munson, Rollins, P. R., & Snow, C. E. (1998). Shared attentionMeltzoff, & Dawson,, 2006). and grammatical skills in typical children and children with autism. Journal of Child Language, 25, 653–673.Joint attention skills are very important as research hasshown they are linked to positive outcomes in later 4. Modeling.communication and social skills, therefore it is These interventions rely on an adult or peer providingimportant to teach joint attention skills during early a demonstration of the target behavior by the infantintervention (Rollins, 1994: Rollins & Snow, 1998). or toddler with ASD. Modeling can include simpleJoint attention includes the following types of behaviors: and complex behaviors. This intervention is oftena) A parent and child looking at an object together, combined with other strategies such as promptingb) A parent and child making eye contact, and reinforcement. In figure 4, the team is using a sibling to model how to push a train (functional toy-c) A child pointing to an object to show their interest play skill on the IFSP). to his or her parent,Figure 4 Model Additional Strategies used Prompting Sibling demonstrates how to Child independently pushes push the train on the track Positive reinforcement the train on the track and and says “choo-choo” says “choo-choo” Shaping22 Early Intervention Colorado
  • 27. activities (Schreck & Foxx, 2005). If a child does not Where to get more information on Modeling respond in a teachable moment, such as reaching for Bellini, S., Akullian, J., & Hopf, A. (2007). Increasing a favorite doll, the parent can implement verbal social engagement in young children with autism prompts, saying, “What do you want?” “What is spectrum disorders using video self-modeling. School Psychology Review, 36(1), 80–90. this?” or “doll,” with time-delays to allow the child to respond. Prompting within naturalistic teaching is Hine, J.F., & Wolery, M. (2006). Using point-of-view video modeling to teach play to preschoolers with individualized by the child’s specific communication autism. Topics in Early Childhood Special Education, needs. An example of how naturalistic teaching in the 26(2), 83–93. home can be used is as follows: LeBlanc, L.A., Coates, A.M., Daneshvar, S., Charlop- Jane knows that playing with clay is her daughter Christy, M.H., Morris, C., & Lancaster, B.M. (2003). Using video modeling and reinforcement to teach Amanda’s favorite activity, so she gets down the perspective-taking skills to children with autism. container from the cabinet in the family room where Journal of Applied Behavior Analysis, 36(2), 253–257. the modeling clay is kept. Immediately, Amanda runs over to her mom and pulls at the clay box. Jane blocks Amanda’s hand and looks at her expectantly for a5. Naturalistic Teaching Strategies. request for the clay box. Amanda does not respond,Naturalistic teaching is a structured form of so Jane asks, “What do you want Amanda?” andpresenting learning opportunities in the child’s Amanda says, “Want clay.” Jane then replies, “That’snatural environment utilizing the child’s natural great asking, here is the clay box.” One of Amanda’smotivation and reinforcers, such as using a child’s IFSP outcomes is to identify primary colors, so afterinterest in trains to ask for and play with the train set. Amanda has been playing with the clay for a fewFor children with ASD, naturalistic teaching is minutes, Jane sits next to Amanda and starts to playimplemented to increase generalized language and with a green ball of clay. Jane says, “My clay is green,social skills, and differs from other teaching methods I will make a tree. What color is your clay?” Amandaas it is child-oriented rather than adult-oriented thinks for a moment and then replies, “yellow.”(Fenske, Krantz, & McClannahan, 2001; Hart &Risley, 1968, 1975, 1982). For instance, the child This example used a preferred activity, planned by thetakes the lead on selecting an activity, and the adult parent, but selected by Amanda, to teach her how touses this selected activity as a ‘teachable moment;’ ask for items, and work on her predetermined goal ofan opportunity to be intentional in working with the identifying colors.child on a teaching goal. Naturalistic teachinginvolves an intentional plan to include opportunities Where to get more information on Naturalistic Teachingthroughout a child’s typical daily schedule. Byincorporating teachable moments through the day, Fenske, E. C., Krantz, P. J., & McClannahan, L. E.(2001) Incidental teaching: A non-discrete style teachingany activity or routine can become a teaching approach. In C. Maurice, G. Green, & R. M. Foxxopportunity, such as brushing teeth, eating, playing (Eds.), Making A Difference: Behavioral Interventionball, or looking at a book. The key to successful for autism (pp.75–82). Austin, TX: PRO-ED.naturalistic teaching is to plan the child’s goals and McGee, G.G., Krantz, P.J., & McClannahan, L.E. (1985).objectives and then identify the activities that can The facilitative effects of incidental teaching onoffer teachable moments (Fenske, et al, 2001; Hart & preposition use by autistic children. Journal ofRisley, 1968, 1975, 1982). Applied Behavior Analysis, 18(1), 17–31. McGee, G.G., Almeida, M.C., Sulzer-Azaroff, B., &Once a learning opportunity has been identified, it is Feldman, R.S. (1992). Promoting reciprocalimportant to reinforce the child’s communication interactions via peer incidental teaching. Journal of(attempts) and encourage him or her to elaborate on Applied Behavior Analysis, 25(1), 117–126.the response(s). The teaching moment should remain Strain, P.S., Danko, C.D., & Kohler, F. (1995). Activitybrief and reinforcing so the child does not avoid future engagement and social interaction development ininteractions and all adults in the child’s life should be young children with autism: An examination of “free” intervention effects. Journal of Emotional andtrained to identify similar teachable moments so the Behavioral Disorders, 3(2), 108–123.child can generalize among settings, people and Early Intervention Colorado Autism Guidelines for Infants and Toddlers 23
  • 28. 6. Peer Training Package.With early and intensive intervention, the seemingly Where to get more information on Peer Training Packagepervasive social skill deficits of many children with ASDcan be remediated (Lovaas, 1987; McGee et al., 1993; Kohler, F.W., Strain, P.S., Hoyson, M., & Jamieson, B. (1997). Merging naturalistic teaching and peer-Strain, 1987). If there is such a thing as a “recipe for based strategies to address the IEP objectives ofsuccess,” it must include regular access to typical preschoolers with autism: An examination ofpeers, thoughtful planning of social situations, the use structural and child behavior outcomes. Focus onof “social” toys and multiple-setting opportunities to Autism and Other Developmental Disabilities, 12(4),practice emerging social skills. The Peer Training 196–206.Package involves providing instruction to typical peers Odom, S.L., & Strain, P.S. (1986). A comparison ofto engage the targeted child in frequent and successful peer-initiated and teacher antecedent interventions for promoting reciprocal social interaction of autisticsocial response opportunities. Peers, such as siblings preschoolers. Journal of Applied Behavior Analysis,or other young children at a childcare or other 19(1), 59–71.community setting, are initially taught strategies to Strain, P.S., Kerr, M.M., & Ragland, E.U. (1979). Effectssuccessfully gain the attention of the infant or toddler of peer-mediated social initiations andwith ASD (the target child) followed by strategies to prompting/reinforcement procedures on the socialshare materials that are highly preferred by the target behavior of autistic children. Journal of Autism andchild and later extend to requesting items from the Developmental Disorders, 9(1), 41–54.target child and giving directions around play. Figure 5describes a planned play sequence.Figure 5 Peer or Sibling: Child with ASD: taught to engage child with ASD in may need prompting to typical social scenarios respond appropriately “Hello, want to play kitchen?” “Yes, play” “It’s your turn in the game” or “My turn,” or “Your turn” “Whose turn?” “Can I share that toy please?” “Yes” or “No” or “Soon” “Do you want to play “Play ball” ball with me?”24 Early Intervention Colorado
  • 29. 7. Pivotal Response Treatments. also increase speed of responding. For instance, ifPivotal Response Training (PRT) is a teaching Stacie is motivated to color her picture she willapproach based on the premise that by providing finish it faster than if she was unmotivated.intervention to infants and toddlers with ASD in c) Self-management—teaching in the area of self-pivotal areas, positive collateral effects will occur in management has demonstrated greaterrelated behavior. Teaching fundamental behaviors will independence outcomes as the focus ofhave far-reaching effects on the child acquiring other responsibility is shifted from the parent to thebehaviors beyond those that were taught. For child. The child will learn to make choices andinstance, teaching in the area of functional monitor behavior so he or she can learn tocommunication may produce a decrease in self- function in different environments and learn thatinjurious behavior, and teaching social skills can have his or her behaviors cause environmental change.collateral effects on language development. PRT involves using ABA procedures, includingAreas that are targeted as pivotal include: functional communication, shaping and chaininga) Multiple cues—teaching responses to a variety of behaviors, reinforcement, and discrimination. Training cues and reducing stimulus over-selectivity (in typically occurs in the child’s natural environment and which children with ASD typically over generalize often involves parents as teachers. In figure 6, Jahan’s and have a small responding repertoire, such as mother uses functional communication to reduce her saying “dog” to every animal they see). Although 30 month-old daughter’s self-injurious behavior. this generalization is common in all young children, for those with ASD this deficit continues Where to get more information on Pivotal whereas other infants and toddlers without ASD Response Training learn to distinguish different characteristics and Carr, E. G., & Durand, V. M. (1985). Reducing behavior adapt their response repertories. problems through functional communication training. Journal of Applied Behavior Analysis, 18, 111–126.b) Motivation—(measured as the child’s responding) Koegel, L. K., Koegel, R. L., Harrower, J. K., & Carter, C. is targeted as a pivotal area as increases in M. (1999). Pivotal response intervention I: Overview motivation can lead to better social skills, higher of Approach. The Association for Persons with responses in completing tasks and activities and Severe Handicaps, 24(3), 174–185.Figure 6 Self-injurious behavior Functional communication I I N N C C R R E E A A S S E E Jahan stands next to the Mom teaches Jahan functional Jahan now stands next to fridge and bangs her head communication to request the fridge and says “want on it when she is hungry things she wants food” when she is hungry D E C R E A S E Self-injurious behavior Early Intervention Colorado Autism Guidelines for Infants and Toddlers 25
  • 30. 8. Schedules (Use of Visuals). bedroom with pink hearts on the walls, and in Pictures can serve the function of visual Home with Grandma, there is a photograph of herschedules in which children are “shown” what to brushing her teeth with her blue toothbrush anddo, or what comes next in their day. Using visuals sleeping in her bedroom with flowery curtains.are very successful with children with ASD as they Lily’s mom and grandmother look at theare generally visual learners. For an infant or photographs with Lily before she has to go to thetoddler, these visual schedules can be adapted to other house to make sure she knows where she issimply using one or two pictures so the child going and what she is going to do when she getsknows what he or she has to do, such as holding a there, thereby helping her to achieve smoothpicture of a car when a car ride is the next activity transitions during her busy days.(perhaps a non-preferred activity). These pictures 9. Augmentative and Alternative Communication.may help to smooth transitions from one activity Augmentative and Alternative Communicationto the next so the child feels safe when their (AAC) is the term for a variety of tools andenvironment changes, as many children with ASD strategies that support individuals withdo not like change and find transitions very communication impairments or little functionaldifficult. For instance, 32 month-old Lily spends speech. AAC either enhances or “augments” theseveral days a week at her grandmother’s house speaker’s communication or offers an “alternative”while her mother is working. As a shift worker, her to vocal speech. AAC is divided into two mainmom’s schedule changes frequently each week, categories, (a) aided, and (b) unaided. Aided AACmaking it very important to help Lily transition involves using an external object forfrom one house to the other successfully. In order communication (Zangari, 2000). Various forms ofto help Lily, she has two visual schedule books: aided AAC include communication devices, such asone called Home with Mom and the other called electronic communication boards in which the childHome with Grandma. Inside the books there are presses a button to elicit an electronic voice outputphotographs of Lily in the car in front of each (also known as assistive technology). These rangehouse, and lots of photographs of the different from simple devices with a few communicationactivities and tasks for her to do in each of the outputs, to highly advanced computers andhouses. For instance, in her book Home with Mom, personal digital assistants (PDAs). It is alsothere is a photograph of her brushing her teeth possible to have a same-age, same-sex peer towith her yellow toothbrush and sleeping in her record the vocals for the output. Less technical forms of AAC include using pictures as Where to get more information on Schedules communications, for instance, the child exchanges a picture of a cup for some juice, or points to a Krantz, P.J., MacDuff, M.T., & McClannahan, L.E. (1993). Programming participation in family activities graphic symbol of a slide to communicate a want to for children with autism: parents’ use of go outside and play. For children who use aided photographic activity schedules. Journal of Applied AAC systems, it is important that the Behavior Analysis, 26(1), 89–97. communicative partners understand how the Massey, N., & Wheeler, J.J. (2000). Acquisition and system works, ensures the system is reachable to generalization of activity schedules and their effects the child at all times, and any high technology on task engagement in a young child with autism in devices must be fully charged or have spare an inclusive pre-school classroom. Education & Training in Mental Retardation & Developmental batteries on hand (Cafiero, 2005; Mirenda, 2009; Disabilities, 35(3), 326–335. Ogletree & Oren, 2006; Zangari, 2000). Some high- O’Reilly, M., Sigafoos, J., Lancioni, G., Edrisinha, C., tech devices may be too advanced for very young Andrews, A. (2005). An examination of the effects of children which may contribute to frustration and classroom activity schedule on levels of self-injury and inappropriate behaviors. Therefore, it is probably engagement for a child with severe autism. Journal of best to begin with simple pictures on cards, or Autism and Developmental Disorders, 35, 305–311. simple single pictures on electronic devices for this young population.26 Early Intervention Colorado
  • 31. Unaided AAC systems do not require an externalobject in order for the child to communicate. An Where to get more information on Augmentative and Alternative Communicationexample of an unaided system is sign language, inwhich a child uses his or her hands, or other symbols, Assistive Technology Partners. University of Colorado Denver School of Medicine. 303-315-1280signs, and gestures. Again, the consideration is thatthe communicative partner understands the system Cafiero, J. M. (2005). Meaningful exchanges for people with autism. Bethesda, MD: Woodbine House.used, especially if the signs or gestures are child-specific (Cafiero, 2005; Mirenda, 2009; Ogletree & Drager, K.D. R., Light, J. C., & Finke, E. H. (2009). Using AAC technologies to build social interactionOren, 2006; Zangari, 2000). with young children with Autism SpectrumThe use of AAC with infants and toddlers with ASD Disorders. In P. Mirenda & T. Iacono (Eds.), Autism Spectrum Disorders and AAC (pp.247). Baltimore:is a complex area as the unique needs and Paul H. Brookes.communication impairments among this population Light, J., Roberts, B., DiMarco, R., & Greiner, N. (1998).vary. Not all children with ASD will require AAC, but, Augmentative and alternative communication tofor some, the use of an AAC system can temporarily support receptive and expressive communication for(until speech develops) or permanently aid their people with autism. Journal of Communicationfunctional communication (Mirenda, 2009). Disorders, 31, 153–180.However, the decision to implement a system Ostryn, C., Wolfe, P.S., & Rusch, F. R. (2008). A reviewpresents a multitude of challenges and and analysis of the picture exchange communicationconsiderations in order to select the most useful system (PECS) for individuals with Autism Spectrum Disorders using a paradigm of communicationsystem to meet a child’s individualized needs competence. Research & Practice for Persons with(Drager, Light, & Finke, 2009). Severe Disabilities, 33, (1–2), 13–24. Early Intervention Colorado Autism Guidelines for Infants and Toddlers 27
  • 32. Case StudiesIn order to provide the reader with examples of the Established Interventions in action, the following materialreviews three case studies. For each case, a brief set of descriptive information is offered along with a tabledsubset of individualized intervention plans that were developed by the IFSP team using the aforementioned“About Our Child” protocol and the RBI. Carlos’ team used the content of Table 1 to complete the assessment,outcomes and services and support sections of his IFSP.Case Study 1: Carlos. Carlos is a 24 month-old little boy who lives with his mother, father and three sisters (two older and one infant). Carlos is not using any spontaneous functional language, although his parents report hearing him say a few words. He occasionally imitates a sound, usually after his parents have repeated a sound he has just made. Carlos does not indicate his wants or needs or ask for things. If he needs something he often whines and his parents try to figure out what he wants. He also walks to the refrigerator and stands next to it when he wants something to eat or drink. Carlos drinks from a sippy cup and feeds himself with his fingers, but is not using utensils yet. Carlos does not make consistent eye contact with his parents or siblings and, while he occasionally approaches his parents, he generally ignores his sisters unless they initiate with him. They are most successful in engaging him in rough and tumble play. Carlos has limited play skills and interest in toys. He plays, briefly, with some cause and effect toys that make noise or light up but generally spends his time wandering around, taking toys off the shelf, looking at them and then dropping them and moving on. He also shows some interest in shiny toys and mirrors. When wandering, Carlos frequently flaps his hands and occasionally engages in other self-stimulatory behaviors, such as staring at his fingers and/or looking at things out of the corners of his eyes.Based on this information gathered from the RBI and the “About Our Child” protocol, the following prioritieswere identified by Carlos’ family: a) help with dressing in the mornings and evenings; b) asking (either usingwords or with pictures) for what he wants; c) interacting with others (play with children and (saying “hi” and“bye” to people), and d) playing with toys like other kids his age.Table 1: Carlos’ “Established Interventions” Setting and Priority Outcomes Methodologies and Strategies Participants Dressing/Diaper Changes Carlos will Carlos will assist Home with Antecedent Package: Most-to-least prompting (use physical help dress with dressing by mom or dad. prompting initially, then fade to partial physical, then to verbal himself. pulling his pants cues). Providing choices of what to wear. up and down. Carlos will Carlos will request home and Visuals: Have pictures of his favorite food and drink items velcroed Snacks and Meals ask for what a snack by using childcare to the refrigerator door. he wants. pictures or words. parents, Naturalistic Teaching & Visuals: When Carlos stands by the childcare refrigerator, prompt him to look at the pictures and select what he providers, wants. Once Carlos selects a picture, model the verbal response “I siblings, peers want cheerios” and immediately follow-up with the delivery of the and therapists requested item. Provide small snack portions to allow for multiple requesting opportunities.28 Early Intervention Colorado
  • 33. Table 1: Carlos’ “Established Interventions” (continued) Setting and Priority Outcomes Methodologies and Strategies Participants Carlos will Carlos will home and Antecedent Package: Provide least-to-most prompting to respond Greetings and Farewells say “hi” and respond to adult childcare (if Carlos does not respond to the greeting then verbally cue him to “bye” to and peer greetings wave, if he does not respond provide physical assistance with the people. by waving. verbal cue). Before entering childcare, remind Carlos that he is going to “wave hi” to the teacher and his friends. parents, Peer Mediated: Childcare providers will remind two or three peers childcare to come and greet Carlos each day. providers siblings, peers and therapists Carlos will Carlos will play home and Naturalistic Teaching & Pivotal Response Treatments: Provide play with appropriately with childcare multiple, desired toys for Carlos to play with. Follow cues to toys like cause and effect determine his favorite toy. other kids toys, such as his his age. “See and Say,” for Play Time 10 minutes. Carlos will Carlos will accept parents, Modeling: Adults and peers will model how to use the toy Carlos play with toys from peers. childcare has selected. other providers Peer Mediated: Have peers play with the chosen toys along with children. siblings, peers Carlos. Peers will provide assistance to Carlos to use toys and therapists appropriately. Peers will offer (share) play materials with Carlos Carlos will Carlos will help home and Antecedent Package: Have clear plastic containers for each toy play with clean up toys after childcare clearly labeled with pictures of the item. toys (includ- playing with them. Clean Up ing cleaning parents, Provide least-to-most prompting to participate in cleaning up up). childcare (adults will start with a verbal prompt and proceed to partial providers, physical and full physical prompting only as needed). siblings, peers and therapists Carlos will Carlos will request Home with Antecedent Package: Carlos’ family has pictures of five of Carlos’ ask for what one of his favorite mom, dad, favorite videos. he wants. videos. sisters. TV Time Peer-Mediated: One of Carlos’ older sisters will present him with two video choices. Naturalistic Teaching: When appropriate, parents will follow Carlos’ lead, prompting him to request a video when he shows interest. Early Intervention Colorado Autism Guidelines for Infants and Toddlers 29
  • 34. Case Study 2: Nick. Nick is a 32 month-old boy of recently divorced parents who have joint custody. He lives at home with his mother, but spends Friday, Saturday and Wednesday nights with his father. Nick communicates effectively using three and four word phrases to request and comment. Nick also has some preservative language and at times he recites scenes from favorite TV shows and movies. When he is doing this he is very hard to distract and redirect to something appropriate. Nick appears to show interest in other children and watches them play, although he seems to have trouble interacting with them. His parents report that he likes to play “his way” and attempts to redirect him generally result in Nick getting frustrated. When other children have toys or materials he wants, he generally tries to take them by force, but doesn’t usually use aggression. He simply tries to take the toy out of their hand and say things like “My Thomas!” Nick’s parents also report a good deal of frustration with his ability to follow routines. Because of the recent separation, Nick’s routine is constantly changing and they report he has a difficult time with this. Bed time is especially difficult and his mom reports getting Nick to stay in his room and go to sleep is a nightly battle.Based on this information gathered from the RBI and the “About Our Child” protocol, the following prioritieswere identified by Nick’s family: a) using sentences when asking for things; b) playing with other children andsharing toys; c) following routines; and d) staying in his room at bedtime.Table 2. Nick’s “Established Interventions” Setting and Priority Outcomes Strategies and Methodologies Participants Nick will use Nick will ask for home and Naturalistic Teaching: Allow Nick to choose and request what he Meals and Snacks sentences to the food that he childcare wants for breakfast. Prompt Nick to verbally ask for the desired ask for what wants using food, “I want yogurt, please,” when given choice of foods. he wants. complete sentences. Nick will Nick will help clean parents and Schedules: Use picture cues (sink) to remind Nick to bring his follow a up his dish(es) childcare dish(es) to the sink. routine. after eating. providers Nick will Nick will request a Home or Naturalistic Teaching: Give peers one of Nick’s favorite toys. play cooper- turn with a toy community Prompt Nick to request the toy, “I want truck, please,” while putting atively with during each with peers. out his hand or pointing to the toy. other chil- playtime with dren. others. Play Time Nick will give a toy Peer-Mediated: Adults will cue one or two peers to request toys to a peer when from Nick. requested during Antecedent Prompting: Adult will provide Nick with least-to-most each playtime with prompting (use verbal prompting initially then partial physical others. assistance, then full physical assistance only if necessary) to give toys to peers and wait for another turn. Nick will Nick will be home or Antecedent Prompt: Interrupt Nick, redirect to current task using participate in engaged in at least childcare most-to-least prompting. Praise after completion. activities two activities Throughout the Day throughout during the day the day. without reciting Peer-Mediated: Use peer to cue Nick to look at the toy. scenes. Nick will Nick will take off Home with Schedules: Use pictures of the three tasks that Nick has to perform: participate in his coat and shoes mom or dad. 1) take off coat, 2) take off shoes, 3) wash hands. Provide most to daily tasks. and wash his least assistance. hands after he comes inside from playing outside.30 Early Intervention Colorado
  • 35. Table 2. Nick’s “Established Interventions” (continued) Setting and Priority Outcomes Strategies and Methodologies Participants Nick will Nick will complete Home with Positive Behavioral Interventions and Supports Package—PBIS follow the his bedtime mom or dad. Antecedent prompt: Provide countdown to bedtime, 10 minutes, 5 bedtime routine each night. minutes, 2 minutes. Provide least-to-most prompting to complete routine. each step of the bedtime routine. Schedules: Show Nick his bedtime schedule and review the bedtime routine: 1) PJs picture, “we are going upstairs to put on PJs.” 2) Toothbrush picture, “then we are going to brush your teeth so they stay nice and healthy and shiny.” 3) Book picture, “then you get to Bed Time pick a book.” 4) Sleep picture, “then it will be time to turnout the light.” Consequence Strategy (Reinforcement): Provide praise for getting through each step of the routine. Once Nick is in bed he can pick which story he wants to hear. Use these books only for bedtime routine. Nick will Nick will sleep in Consequence Strategy (Redirection): If Nick leaves his room, sleep in and his bed throughout matter-of-factly redirect him back to bed. Limit attention (eye stay in his the night. contact, talking to him) to only what is necessary. Use positive own bed. language, (i.e., “you need to stay in bed.”). Early Intervention Colorado Autism Guidelines for Infants and Toddlers 31
  • 36. Case Study 3: Hannah. Hannah is a 30 month-old girl who lives with her mother and father. She was just diagnosed with ASD, although her parents had expressed concerns to their pediatrician starting at around 18 months. Hannah has good use of nouns to label and request objects, can use some verbs in two to three word combinations and also has a variety or rote phrases that she uses mostly out of context or to calm herself (e.g., “We don’t bite,” “I know what you mean” or “Don’t poke eyes”). Hannah demonstrates what her parents call selective hearing, at times responding well to their requests and at other times appearing to not hear them at all. Hannah seeks out sensory input and likes to play with items like play dough and shaving cream and also likes activities like swings and jumping on the trampoline, but she demonstrates little functional play with traditional age appropriate toys like dolls or blocks. In social situations, Hannah, at times, approaches other adults, although she seems more hesitant with men than women. She generally shows little interest in other children her age, however, when peers initiate an interaction with her she often is aggressive trying to scratch or bite them. Hannah’s parents are hesitant to bring her to play with other children or take her to places other children go because of the likelihood of her biting another child. Hannah gets very upset when her routine changes or she is asked to stop doing something she enjoys. At these times she generally falls to the ground, screaming or crying. In these situations when she is frustrated Hannah occasionally demonstrates self-injurious behavior, including biting or scratching her arm and poking her eyes with her thumbs.Based on this information gathered from the RBI and the “About Our Child” protocol, the following prioritieswere identified by Hannah’s family: a) using sentences when asking for things and expressing herself whenupset; b) playing with toys and other children; c) transitioning from one activity to another; d) completingeveryday routines and e) decreasing self-injurious behavior.Table 3. Hannah’s “Established Interventions” Setting and Priority Outcomes Strategies and Methodologies Participants Hannah will Hannah will Home with Antecedent Package: Give Hannah a two minute warning before the Dressing and Diaper Changes calmly remain calm while mom or dad. diaper change. Use least-to-most prompting for diaper changes and transition to transitioning from dressing. diaper the previous changes. activity to diaper changing. Hannah will Hannah will help Schedules: Use pictures of each article of clothing and a visual complete an dress herself each schedule for what Hannah needs to put on for dressing. everyday morning. routine. Hannah will Hannah will home or Schedules: Use pictures of daily activities/routines as a visual move from successfully end community schedule. If Hannah protests during a transition, use least-to-most Transitions activity to one activity and prompting to have her check her schedule and review what she activity move on to the needs to do next. without next throughout getting the day. upset. Hannah will Hannah will Home or Naturalistic Teaching: When Hannah requests food or drink, Meal Time be able to request foods community prompt her for a sentence by saying “I…” and using wait time. After tell us what using 3+ word with parents 2 prompts, accept her 1 or 2 word request. she wants to sentences during or other eat. meal time. adults. Hannah will Hannah will take Home or Modeling: Adults and peers will model appropriate play for Hannah. Play Time play cooper- turns in play with a community Give play direction and use least-to-most prompting. atively with friend or adult at with parents, Use preferred materials (sensory) and commenting to encourage others. home or peers and joint attention around play materials. playgroup. teachers.32 Early Intervention Colorado
  • 37. Table 3. Hannah’s “Established Interventions” (continued) Setting and Priority Outcomes Strategies and Methodologies Participants Hannah will Hannah will community Peer Mediated: Peers at the playgroup will be prompted to say “hi” interact with independently say center to Hannah. Hannah will be verbally prompted by the teacher to other chil- “hi” to a peer in playgroup with respond by saying “hi” to the peer. dren. response to the mom, teacher, peer’s initiation and five peers. when arriving at playgroup. Hannah will accept In response to Hannah’s “Hi,” peers will give Hannah a small play an item from a dough container or other preferred sensory materials. peer. Hannah will Hannah will Naturalistic Teaching: Once Hannah has 2 or 3 play dough show that identify 5 colors containers, the classroom teacher will use them to teach Hannah she has the while at the colors. skills that playgroup. other chil- dren her age have. Hannah will Hannah will Discrete Trial Training: One of Hannah’s therapist’s (speechPlay Group have aware- identify where pathologist) will meet her at the playgroup on a daily basis. The ness of her things are at therapist will join Hannah in her routine and will work on expanding environ- playgroup through vocabulary by asking Hannah and her peers to expressively identify ment. the understanding prepositions in the environment. of 10 prepositions, such as beneath, over, under, etc. Hannah will Hannah will follow Positive Behavioral Interventions and Supports: Give Hannah participate in simple one-step short, one-step directions, and to allow at least 5 seconds for her to playgroup directions during respond. activities activities at the without playgroup. Teach peers to approach Hannah slowly, making sure that she sees screaming or them coming toward her. Peers will give Hannah preferred sensory injuring her- materials. self or oth- ers. If Hannah attempts to bite, an adult will interrupt her, show her a Hannah will picture of a stop sign and redirect her to a different activity (such as remain calm when completing a puzzle). approached by a peer. Once calm, she will be offered to engage in a preferred activity with the peer or adult that triggered the aggressive behaviors. Hannah will Hannah will Hannah and Antecedent Prompts: Around 7:30, Hannah’s dad will give her a 5 successfully willingly transition dad at home. minute warning that it will be time for bed soon. follow her from after dinner bedtime activities toBed Time routine. bedtime activities. Hannah will brush Schedules and Antecedent Prompts: Use pictures of bedtime her teeth with activities/routines as a visual schedule. If Hannah protests during a adult support. routine use least-to-most prompting to have her check her schedule and review what she needs to do next. Early Intervention Colorado Autism Guidelines for Infants and Toddlers 33
  • 38. While choosing from a set of evidence-based Incidental Teaching, for example, to teachinterventions is essential, this act alone does not language to Aaron is slightly different than theensure good outcomes for specific infants or best version to teach language to Karen. Only bytoddlers. It is equally important to have monitoring using ongoing data systems can providers hopesystems in place to track child progress. The to make these small but incredibly importantfollowing section provides several examples of variations for each child and family.effective and efficient progress monitoring systems. The challenge is to select measurement methods that yield meaningful data, while at the same time notMonitoring Progress being too burdensome to all involved. In recentThe link between achieving good outcomes for years, a variety of relatively simple behavior ratinginfants and toddlers with ASD and their families and scales have been utilized by parents and providers tothe use of ongoing data collection is clear and achieve these dual purposes (Dunlap et al., 2010;undeniable. Every Established Intervention described Strain & Schwartz, 2009).within this Guidelines document has only been usedin conjunction with ongoing data collection. Within The following is an overview of sample rating scalesthe context of early intervention for infants and that have been used to track a wide variety oftoddlers with ASD, careful progress monitoring is behavioral outcomes.essential because: For use with general cognitive, adaptive, and self-1. No practice is universally effective, and thus, there help skills a “Prompting Hierarchy Scale” is is a professional and ethical imperative to detect recommended. less than desired effects and change methods in a The categories in the hierarchy are: timely manner. 4 = Child can complete the skill independently or when given2. Many of the behaviors targeted for change (e.g., a group direction. tantrums, self-injury, repetitive speech) with this 3 = Adult points/gestures/models/or verbally directs the child population engender strong emotions in both to perform skill. families and providers by their presence or 2 = Adult provides partial physical assistance to complete absence. Thus, it is essential to have methods for skill, but child can do some independently. the objective measurement of behavior over time. 1 = Adult provides 100% physical (hand over hand)3. Many Established Interventions rely on incoming assistance to complete skill. data to make individualized modifications and 0 = Child refuses to perform skill; walks away; ignores adult; accommodations to reach maximum says “No”; tantrums. effectiveness. That is, the best version of ND = No data for that session. Objective Date 9/15 9/16 9/17 9/18 9/19 9/20 9/21 9/22 9/23 9/24 9/25 9/26 9/27 9/28 9/29 9/30 10/1 10/2 10/3 10/4 Carlos will 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 remove 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 socks and 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 shoes. Level: 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Criteria: 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 sessions ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND4 = Child performs skill independently or when given a group direction. No adult intervention is needed3 = Adult points/gestures/models/ or verbally directs child to perform skill2 = Adult provides partial physical assistance to complete skill but child can do some independently1 = Adult provides 100% physical (hand over hand) assistance to complete skill0 = Child refuses to perform skill, walks away, ignores adult, says “No,” tantrumsND = No data for that session34 Early Intervention Colorado
  • 39. The contemporary level or criterion for each objective providers or parents circle the level at which moreis set one level above the child’s current capability. tick marks were placed. If two levels receive the sameFor example, if the objective is to “remove socks and number of tick marks, then the lower level is circledshoes,” and the child can currently take off his socks because the goal is for mastery. Once the child is atand shoes with partial assistance, then the level to be Level 3 for several (3–5) consecutive days the Teamachieved is set at Level 3. Each time the child should shift the criterion to Level 4—independentattempts the task a tick mark is placed by the level at performance.which the task was performed. At the end of the day,For use with objectives where the basic goal is to have the child comply with a necessary routine, such asdiapering, the following type of hierarchy scale is recommended. Just like the previous scale, an initialperformance level is set one step above the child’s baseline performance and work continues until“independent” performance is achieved. Objective Date 9/15 9/16 9/17 9/18 9/19 9/20 9/21 9/22 9/23 9/24 9/25 9/26 9/27 9/28 Hannah will 4 4 4 4 4 4 4 4 4 4 4 4 4 4 collaborate with 3 3 3 3 3 3 3 3 3 3 3 3 3 3 diaper changing 2 2 2 2 2 2 2 2 2 2 2 2 2 2 routine. Level: 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Criteria: 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 sessions ND ND ND ND ND ND ND ND ND ND ND ND ND ND4 = Hannah independently stays on changing table while being changed.3 = Hannah wiggles 2 or 3 times during changing routine, but adults are able to complete the routine while providing Hannah with verbal prompts.2 = Hannah sits on changing table, kicks her legs. Adults have to interrupt the routine more than one time.1 = Adult physically prompts Hannah to stay on changing table. Two adults are needed to complete the routine.0 = Hannah refuses to stay on changing table, tantrums, bites, scratches.ND = No data for that sessionFor use with objectives that involve verbal language production, the following type of hierarchy scale isrecommended. This is, of course, a version of a prompting hierarchy, but one specific to verbal behaviors wherephysical prompting is not possible. Objective Date 9/15 9/16 9/17 9/18 9/19 9/20 9/21 9/22 9/23 9/24 9/25 9/26 9/27 9/28 Nick will request 4 4 4 4 4 4 4 4 4 4 4 4 4 4 breakfast items 3 3 3 3 3 3 3 3 3 3 3 3 3 3 using 2–3 words 2 2 2 2 2 2 2 2 2 2 2 2 2 2 sentences. 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Level: 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Criteria: 5 sessions ND ND ND ND ND ND ND ND ND ND ND ND ND ND4 = Nick requests items using 2–3 word sentences independently. No adult support is necessary.3 = Adult points to wanted items to remind Nick to request them verbally. Adult may point to “I want” card.2 = Adult takes Nick to the area where wanted items are and holds one of the items up for Nick to request it.1 = Adult takes Nick to area where desired items are, shows him the items, their pictures, and asks for verbal imitation of the request.0 = Nick refuses to request any of his favorite items, walks away, tantrums.ND = No data for that session Early Intervention Colorado Autism Guidelines for Infants and Toddlers 35
  • 40. For peer social behavior objectives, the recommended hierarchy focuses on varying levels of complex peer play. Objective Date 9/15 9/16 9/17 9/18 9/21 9/22 9/23 9/24 9/25 9/28 9/29 9/30 10/1 10/2 Hannah will stay in 5 5 5 5 5 5 5 5 5 5 5 5 5 5 proximity and 4 4 4 4 4 4 4 4 4 4 4 4 4 4 plays with peers for 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 minutes. Level: 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Criteria: 1 1 1 1 1 1 1 1 1 1 1 1 1 1 5 sessions5 = Stayed in proximity to peers and played for >3 minutes.4 = Stayed in proximity and briefly joined in play with peers 1–3 minutes3 = Stayed in proximity to peers and engaged in parallel play2 = Stayed in proximity and watched others1 = Actively avoided peersMaking Smart Decisions AboutData SystemsThere are two sets of decisions that are crucial in goal here is to have a reliable system of data reviewusing data. The first has to do with the frequency or in place such that infants and toddlers and theirintensity of data collection. While it is imprudent to families are not needlessly exposed to ineffective oroffer fixed, theoretical guidance, we can suggest the less than optimal interventions. Many of the mostfollowing considerations. First, if target behaviors are widely researched and replicated models of earlyconsidered crucial to safety and well being (e.g., self- autism services (e.g., LEAP; Project Data, Waldeninjury, running into street, hurting others), then the Preschool, Princeton Child Development Center, etc.)team should consider maximizing data collection employ a very similar decision-making system.resources accordingly. Second, anytime a new skill is Specifically, the operational rule is that the IFSPtargeted or a new tactic is implemented, the team team must meet to discuss potential modificationsshould consider these events as occasions for more to any intervention after two weeks (10 successiveintensive data collection. data-days) of data indicating no progress or regression. In many cases, the outcome is not toA second set of decisions center on the adoption of abandon an approach but to see if it is beingguidelines under which decisions are made implemented faithfully, or if it needs to be fine-tunedregarding changes to intervention approaches. The to address some unique child need or preference.36 Early Intervention Colorado
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  • 45. Appendix A. Questions to Guide the Individualized FamilyService Plan Planning Process for Children with AutismSpectrum DisordersThe following checklist is provided for early intervention teams to guide the IFSP planning process for childrenwith ASD in order to support the delivery of services that are comprehensive, individualized, evidenced-basedand of sufficient intensity: Question Response1. Have assessment strategies been utilized to document the child and family needs identified in the IFSP that are: a) Specific (observable, measurable, and valued by adult family members)? Yes No b) Functional (related to specific skills that help the child access everyday life)? Yes No2. Are there evidence-based strategies in place that: a) address each area of need identified by the team? Yes No b) include functional outcomes addressing the defining characteristics of ASD Yes No (communication, social skills, and behavioral concerns)? c) specifically addresses the child and family being successful with daily routines (e.g., Yes No dressing, feeding, bedtime, community outings, etc.)? d) include strategies to equip family members with the information and skills needed to Yes No provide consistency in intervention when early intervention providers are not present?3. Has the IFSP team carefully considered the following taking into account the child’s developmental availability for intervention and the families dynamics and available resources: a) What early intervention services are needed to implement the evidence-based practices? Yes No b) Who will deliver the services? Yes No c) Where the services will be provided? Yes No d) When and how frequently the services will occur? Yes No e) What available funding sources will be accessed? Yes No4. Are the proposed providers fluent with the evidence-based practices to be delivered? If not, Yes No what plans are in place to provide training, supervision or coaching for those providers?5. Is there a plan in place whereby multiple providers, if utilized, meet frequently to Yes No communicate, plan logically consistent services and review progress?6. Do the planned strategies include an ongoing data collection system and clear decision-making guidelines regarding the continuation or modification of the plan Yes No that results in progress for meeting child and family outcomes? Early Intervention Colorado Autism Guidelines for Infants and Toddlers 41
  • 46. Appendix B. About Our ChildChild’s Name: _______________________________________________ Date: ________________________ Priority We would We would We would What our child knows or Skills we would like our child Level (low, like like to work like Area already does in this area: to learn in this area: medium or information on this at strategies for high) about this home teaching this Play Skills (skills such as appropriate toy play, sharing, taking turns, playing by self, playing with other children...) Language & Communication (skills such as communicating needs, following directions, listening skills, concepts such as in, on, up, down...) Adaptive / Self Help (skills such as dressing, undressing, zipping, buttoning, toilet training, sitting or standing at potty, toileting schedule...) Meal Time (skills such as eating with utensils, eating more of a variety of foods, pouring juice, eating more slowly, table manners...) Bath time (skills such as sitting (staying) in the tub, washing self, combing hair, brushing teeth....) Community Activities (skills such as shopping with family members, eating out in restaurants, riding in the car...) Cognitive (skills such as understanding cause and effect, identifying numbers, letters, colors, shapes; sorting objects...) Motor (skills such as running, jumping, playing ball, coloring, building with blocks...) Behavior (Behaviors that interfere with learning or that you would like your child to do less often...)42 Early Intervention Colorado